COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come or enter our center.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Fever (usually 37.2 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT enter our premises. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Stayed in a non MGCQ/GCQ area?

If you answered “Yes” to any part of question two, please DO NOT enter our premises. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Brgy.

CityState / Province

Postal / Zip Code
Body Temperature*
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty: