Daily Health Questionnaire
Visitor
Participant
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Child's Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
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1. Is your child currently experiencing any of the following symptoms? Choose any/all that apply.
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Fever(a temperature of 37.8 degrees Celsius or higher)
Chills
Cough that's new or worsening(continuous, more than usual)
Croup (barking cough, making a whistling noise when breathing)
Shortness of breath(out of breath, unable to breathe deeply)
Sore throat
Difficulty swallowing
Runny, stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Lost sense of taste or smell
Conjunctivitis (pink eye)
Headache (that's unusual or long lasting)
Digestive issues like nausea/vomiting, diarrhea, stomach pain (not related to other known causes or symptoms)
Muscle aches (that are unusual or long lasting)
Extreme tiredness (that is unusual or long lasting)
Unexplained or increased number of falls
Sluggishness or lack of appetite
None of the above
1. Are you currently experiencing any of the following symptoms? Choose any/all that apply.
*
Fever(a temperature of 37.8 degrees Celsius or higher)
Chills
Cough that's new or worsening(continuous, more than usual)
Croup (barking cough, making a whistling noise when breathing)
Shortness of breath(out of breath, unable to breathe deeply)
Sore throat
Difficulty swallowing
Runny, stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Lost sense of taste or smell
Conjunctivitis (pink eye)
Headache (that's unusual or long lasting)
Digestive issues like nausea/vomiting, diarrhea, stomach pain (not related to other known causes or symptoms)
Muscle aches (that are unusual or long lasting)
Extreme tiredness (that is unusual or long lasting)
Unexplained or increased number of falls
Sluggishness or lack of appetite
None of the above
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2. In the last 14 days, has your child been in close physical contact with someone who tested positive for COVID-19? (close physical contact means being less than 2 metres away in the same room, workspace, or area for over 15 minutes or living in the same home)
*
Yes
No
2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? (close physical contact means being less than 2 metres away in the same room, workspace, or area for over 15 minutes or living in the same home)
*
Yes
No
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3. Has your child traveled outside of Canada in the last 14 days?
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Yes
No
3. Have you traveled outside of Canada in the last 14 days?
*
Yes
No
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Date
*
-
Month
-
Day
Year
Date
By providing answers to this questionnaire and signing below, you confirm that all answers are accurate.
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