Covid-19 Form | Paper Scissors Paint

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Will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements.

First Name

Last Name

Email

Phone

Do you, or anyone in your household have any of the following symptoms:

Fever

Cough

Shortness of Breath

Runny Nose

Sore Throat

Chills

Painful Swallowing

Nasal Congestion

Fatigue

Nausea/Vomitting/Diarrhea

Loss of Appetite

Loss of Sense of Taste/Smell

Muscle/Joint Aches

Headache

Conjuctivitis

NO SYMPTOMS

Have you, or anyone in your household had close contact with a confirmed case of Covid-19 in the last 14 days?

Yes

No

Your Signature

Date

I declare that the information I’ve provided is accurate & complete.

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