Covid Self Assessment Register Employee Nr:00000011847122381224012241122431224321224412246122471224912250122501229512295122951254913023131401329313342135171354662656887688774388412868389319900testContactHave you been in direct contact with someone known to be infected in the past 14 days?YesNoIndirect ContactHave you been in direct contact with someplace (E.g. Hospital) known to be treating COVID-19 in the past 14 days?YesNoAnother ProvinceDid you travel to another Province?YesNoRespiratory rate?NormalAbove NormalPulse rate?NormalAbove NormalCoughingAny coughing?YesNoSore ThroatSore throat?YesNoShort BreathShortness of Breath?YesNoLoss of smell OR loss of tasteLoss of smell OR loss of taste?YesNoFever-chillsDaily Fever/Chills ?YesNoBody achesBody aches/muscle pains?YesNoRedness of the eyesRedness of the eyes?YesNoNausea/vomiting/diarrhoeaNausea/vomiting/diarrhoea?YesNoFatigue/ weaknessFatigue/ weakness?YesNoHeadacheHeadache?YesNoTemperature?*What is your Temperature (no meds)?36.5–37.5 °C(Normal)Above 37.5 °C(Fever)Home or workAt Home or work?HomeWork
