Updated: December 10, 2020
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Date (mm/dd)
If symptoms
connue past
this point
call your
healthcare
provider.
No Symptoms
Symptoms :
Let a health care provider know if you develop symptoms.
Temperature (specify: 0C)
Shortness of breath or diculty breathing Call 9-1-1
Fever
New or worsening cough
Loss of sense of smell / taste
Generally feeling unwell
Chills
Muscle aches
Fague or weakness
Sore throat
Congeson or runny nose
Headache
Diarrhea
Nausea or voming
Loss of appete
Abdominal pain
Skin changes or rash
Other, specify
COVID-19 Active Daily Monitoring Form (for internal use only)
Follow guidance on the Interim Public Health Management of Cases and Contact for direction on duration of symptoms monitoring.
Notes:
If client needs to be seen by a healthcare provider let them know to inform the provider that they are being monitored for COVID-19
Name:
Date of Birth:
Personal Health Number:
Date of Last Contact or Exposure:
Monitoring Start Date:
Monitoring End Date:
Status of Case (check one):
Contact
Suspect (refer to testing if symptoms) Date of Swab:
Probable
Confirmed - Date of Swab:
Date of first symptom onset (if applicable):
