COVID | Journey With Me

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I have not travelled outside of Canada in the past 14 days

I have not tested positive for COVID-19 or had close contact with a confirmed case of COVID-19

I have none of the following symptoms: new onset of cough; worsening of chronic cough; shortness of breath; difficulty breathing; sore throat; difficulty swallowing; decrease of loss of sense of taste or smell; chills; headaches; unexplained fatigue/malaise/muscle aches (myalgias); nausea/vomiting, diarrhea, abdominal pain; pink eye (conjunctivitis); runny nose or nasal congestion without other known cause

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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