COVID-19 Screening Questionnaire

COVID-19 Screening Questionnaire
Name

First Name Last Name
Are you currently experiencing fever and/or chills; cough or barking cough; shortness of breath, decrease or loss of smell or taste; fatigue, lethargy, malaise and/or myalgias; nausea, vomiting and/or diarrhea?

Yes No
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine?

Yes No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes No
In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19?

Yes No
In the last 10 days, have you received a COVID Alert exposure notification on your cellphone?

Yes No
In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

Yes No
In the last 14 days, has someone in your household travelled outside of Canada AND been advised to quarantine?

Yes No
In the last 10 days, has someone in your household been identified as a "close contact" of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate?

Yes No
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Yes No
Please note that proof of vaccination will be requested upon check-in for your appointment. This information will not be stored with PHASES Skin Clinic and you may be asked to provide proof of vaccination for future appointments.
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