COVID-19 Screening Questionnaire

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Name (Conducting Screening) *

Name (Participant) *

Date *

YYYY

Time *

Time

Venue *

Age *

Temperature *

Contact within 48hrs *

Have you been in contact with anyone with or suspected of having COVID-19 in the last 48 hours? Has anyone in your household had COVID-19 symptoms in the last 2 weeks? Have you been advised to self-isolate due to an infection within another setting, such as school?

Yes

Loss of smell or taste *

Have you had any loss of taste or smell?

Yes

New persistent cough *

Do you have a new persistent cough?

Yes

Underlying illness *

Do you have any underlying health conditions that would put you at further risk should you contract COVID-19? (Cardiovascular problems, High blood pressure, Diabetes, Chronic kidney or liver disease, Compromised immunity diseases, Obesity)

Yes

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