A. Do you have a new onset, or worsening, of any ONE of the following symptoms?

Yes

No

• Fever > 38°C or subjective fever/ chills

• Cough

• Sore throat/ hoarse voice

• Shortness of breath/ breathing difficulties

• Loss of taste or smell

• Vomiting or diarrhea for more than 24 hours

If "Yes" to any one of the above, DO NOT ENTER

B. Do you have a new onset, or worsening, of any TWO of the following symptoms?

Yes

No

• Runny nose

• Muscle aches

• Fatigue

• Conjunctivitis (pink eye)

• Headache

• Skin rash of unknown cause

• Nausea or loss of appetite

• Poor feeding (if an infant)

If "Yes" to any two of the above, DO NOT ENTER *

* If you have only one symptom in section B and it has been less than 24 hours since it started, stay home and avoid contact with others. Re-evaluate after 24 hours.

Exposure history

Yes

No

1.

Have you, or a member of your household, been in close contact (within 2 metres / 6 feet for more than 10 minutes total over 24 hours) in the last 14 days with a confirmed COVID-19 case?

2.

Have you been exposed to COVID-19 in a work or public setting?

3.

Have you or a member of your household, traveled outside of Manitoba in the past 14 days and are required to self-isolate (quarantine) **

4.

Is a member of your household sick with COVID-19 symptoms, and waiting for COVID-19 test results? ***

5.

Are you, or a member of your household, waiting for COVID-19 testing results? ***

If "Yes" to any of the above, DO NOT ENTER.