HUNTINGTON ANIMAL HOSPITAL

Name *

First Name

Last Name

How old are you? *

17 years old or younger

18 years old or older

Are you currently experiencing any of these symptoms? *

Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills

Cough or barking cough (not related to asthma, post-infectious reactive airways, COPD or other known pervious conditions)

Shortness of breath (out of breath, unable to breathe deeply)

Sore throat (not related to seasonal allergies, acid reflux, or other known causes)

Difficulty swallowing (painful swallowing)

Runny or stuffy/congested nose

Decrease or loss of taste or smell

Pink eye (conjunctivitis)

Headache (unusual, long-lasting, not related to getting a COVID-19 vaccine in the last 48 hours)

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Muscle aches/joint pain

Extreme tiredness

Falling down often

NONE OF THE ABOVE

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

If the person got a COVID-19 vaccine in the last 48 hours and is experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select 'NO'.

NO

YES

In the last 14 days, have you travelled outside of Canada? *

NO

YES

In the last 14 days, have you been identified as a 'close contact' of someone who currently has COVID-19 *

NO

YES

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

NO

YES

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

NO

YES