MSS COVID-19 Health Questionnaire

COVID-19 Health Questionnaire
Name:

First Name Last Name
Job Number
Date:

Month Day Year
Date
Do You Currently Have The Following Symptoms:
A Fever Over 38 degrees Celsius:

Yes No
Dry Cough or Difficultly Breathing:

Yes No
Aches or Pains:

Yes No
Sore Throat:

Yes No
Diarrhea:

Yes No
Conjunctivitis:

Yes No
Headache:

Yes No
Loss of Taste or Smell, Rash of Skin or Discoloration of Fingers and Toes:

Yes No
Have you traveled outside of Canada in the past 14 days?

Yes No
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill and you did not have appropriate PPE?

Yes No
If you have answered YES to any of the questions above Return to your room and contact your designated Field Supervisor for further instruction.
Signature:

Clear
Should be Empty:

COVID-19 Health Questionnaire