COVID-19 Screening Questionnaire
Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Have you traveled outside of Canada in the past 14 days?
*
Yes
No
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
*
Yes
No
Do you have any of the following symptoms:
*
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore Throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue / malaise / muscle aches (myalgias)
Nausea / vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose or nasal congestion without other known causes
None of the above
Are you 70 years of age or older
*
Yes
No
If yes to the above question are you experiencing any of the following symptoms:
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
None of the above
Submit
Should be Empty: