COVID-19 SCREENING QUESTIONNAIRE

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To screen for COVID-19 symptoms. If client is experiencing any of the following symptoms listed below, please postpone and reschedule visit at least 2 weeks later.

Full Name *

1a. Are you or anyone in the household currently experiencing any of these symptoms: Fever and/or chills? *

Temperature of 37.8℃ /100℉ or higher

Yes

1b. Are you or anyone in the household currently experiencing any of these symptoms: Cough or barking cough? *

Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways)

Yes

1c. Are you or anyone in the household currently experiencing any of these symptoms: Shortness of breath? *

Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)

Yes

1d. Are you or anyone in the household currently experiencing any of these symptoms: Decrease or loss of smell or taste? *

Not related to other known causes or conditions (for example, allergies, neurological disorders)

Yes

2a. Are you or anyone in the household currently experiencing any of these symptoms: Sore throat or difficulty swallowing? *

Painful swallowing, not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

Yes

2b. Are you or anyone in the household currently experiencing any of these symptoms: Runny or stuffy / congested nose? *

Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

Yes

2c. Are you or anyone in the household currently experiencing any of these symptoms: Headache that’s unusual or long lasting? *

Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)

Yes

2d. Are you or anyone in the household currently experiencing any of these symptoms: Nausea, vomiting and / or diarrhea? *

Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps)

Yes

2e. Are you or anyone in the household currently experiencing any of these symptoms: Extreme tiredness that is unusual or muscle aches? *

Fatigue, lack of energy, poor feeding in infants, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction, sudden injury)

Yes

3. Have you or anyone in the household travelled outside of Canada in the last 14 days? *

Yes

4. In the last 14 days, has a public health unit identified you or anyone in the household as a close contact of someone who currently has COVID-19? *

Yes

5. Has a doctor, health care provider, or public health unit told you or anyone in the household that they should currently be isolating (staying at home)? *

Yes

6. In the last 14 days, have you or anyone in the household received a COVID Alert exposure notification on their cell phone? *

Yes

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