PlayFULL Potential COVID-19 Self Screening Questionnaire

PlayFULL Potential COVID-19 Self Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order for your scheduled therapy session to take place. If you answer “YES” to any of the questions, in-person therapy will not occur, your therapist will be in touch to arrange an alternative method of service delivery.

When answering the questions below, please be sure your responses include the health status of ALL members of your household.
Name *

First Name Last Name
Date *

Month Day Year
Date

1) Do you have any new onset (or worsening) symptoms of any of the following? *

	Yes	No
Fever
Cough
Shortness of breath or difficulty breathing
Sore throat
Chills
Painful swallowing
Runny nose/nasal congestion
Feeling unwell/fatigued
Nausea/vomiting/diarrhea
Unexplained loss of appetite
Loss of sense of taste/smell
Muscle/joint aches
Headache
Conjunctivitis (commonly known as pink eye)

In the last 14 days have you: *

	Yes	No
Traveled outside of Canada?
Had close contact* with a confirmed case of COVID-19
Had a close contact* with a symptomatic** person who has had a close contact* with a confirmed case of COVID-19

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