Health Self-Assessment

Name*
First Last
Email Address*
Phone Number*
Which office are you working in or visiting?*
- Surrey Office (#407 - 7337 137 Street)
- Vancouver Office (34 East 12th Avenue)
What day are you working in or visiting this office?*
DD slash MM slash YYYY
Are you experiencing any of the following cold or flu like symptoms, even mild ones?*
- Fever
- Cough (new onset)
- Cough (worsening chronic)
- Sore Throat
- Shortness of breath
- Difficulty breathing
- Loss or decrease of sense of smell or taste
- Runny nose
- Sneezing (not allergy related)
- Hoarse voice
- Nasal congestion
- Chills
- Muscle aches
- Headache
- Unexplained fatigue or malaise
- Difficulty swallowing
- Nausea/vomiting, diarrhea, abdominal pain
- I'm not experiencing any of these symptoms
Have you had close contact with anyone with respiratory illness or a comfirmed probable/suspected case of COVID-19?*
- Yes
- No
Have you been directed/advised to self-isolate as a result of travel or other circumstances?*
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

YES
NO