COVID Screening Questionnaire

COVID Screening Questionnaire

 COUGH or BARKING COUGH (Croup) Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have:(Required)
 FEVER and/or CHILLS Temperature of 37.8°C/ 100°F or higher(Required)
 SHORTNESS OF BREATH Not related to asthma or other known causes or conditions you already have:(Required)
 SORE THROAT Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:(Required)
 DIFFICULTY SWALLOWING Painful swallowing not related to other known causes or conditions you may already have:(Required)
 DECREASE or LOSS OF SMELL or TASTE Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:(Required)
 RUNNY or STUFFY/CONGESTED NOSE Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:(Required)
 HEADACHE Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have):(Required)
 DIGESTIVE ISSUES LIKE NAUSEA/VOMITING, DIARRHEA, STOMACH PAIN Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have:(Required)
 MUSCLE ACHES/JOINT PAIN Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have):(Required)
 FATIGUE Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have):(Required)
 FALLING DOWN OFTEN For elder people(Required)
2. Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (stay at home)?(Required)
3. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?(Required)
4. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?(Required)
5. In the last 14 days, have you or anyone in your home, travelled outside of Canada?(Required)
6. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?(Required)
Patient Name:(Required)
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