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First Name
Last Name
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Are you completing this assessment for a child/youth? *Child/youth refers to individuals under 18, as well as individuals attending high school who are 18 or older.
Yes
No
Are you experiencing any of the followig:
Severe difficulty breathing
Severe chest pain
Having a very hard time waking up
Feeling confused
Lost consciousness
No
Are you experiencing any of the following:
Shortness of breath at rest
Inability to lie down because of difficulty breathing
Chronic health conditions that you are having difficulty managing because of your current respiratory illness
No
In the past 10 days, have you experienced any of the following:
Fever
New onset of cough or worseninh of chronic cough
New or worsening difficulty breathing
Sore throat
Runny nose
No
Do you have any of the following:
Chills
Painful swallowing
Stuffy nose
Headache
Muscle or joint ache
Feeling unwell, fatigue or severe exhaustion
Nausea, vomiting, diarrhea or unexplained loss of appetite
Loss of sense of smell or taste
Conjunctivitis (pink eye)
No
In the past 14 days, were you notified that you are connected to an outbreak OR that you are close contact of a confirmed case of COVID-19 by:
Yes
No
In the past 14 days, did you return from travel outside of Canada?
Yes
No
Do you require testing for the purpose of outgoing travel?
Yes
No
Take steps to protect yourself and others.
All Albertans have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.
Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.
Practice good hygiene: wash your hands often, cover coughs and sneezes and avoid touching your face.
If you do develop any COVID-19 symptoms, stay home and take this self-assessment again.
By signing this you are a verifying that all the information is true
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Daily Client COVID-19 Assessment
