RNYC Covid Form


* Required  


*Name:  

*E-mail:  
1.  Do you have any new or worsening of the following symptoms (that are not chronic or related to other known causes or conditions)?
Fever and/or Chills (temperature of 37.8°C/100.0°F or greater)
A headache that is unusual or long lasting
Cough or barking cough
Difficulty breathing/ shortness of breath
Sore throat/trouble swallowing
Runny or stuffy/ congested nose
Loss or decrease of taste or smell
Feeling unwell
Unexplained fatigue/muscle aches
Pink eye
Nausea/vomiting/diarrhoea
Falling down often
2.  Have you been in close contact with someone who has tested positive or a probable case of COVID-19 in the past 14 days?
3.  Is anyone in your household currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
4.  Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
5.  Has Public Health or the COVID-19 app notified you as being exposed to COVID-19 and required you to self-isolate?
6.  Have you or anyone in your household returned from travel outside of Canada in the past 14 days?
*CONFIRMATION: I have read, understood, and answered No to all of the above questions.   
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