COVID-19 Screen Questionnaire
All staff or guests must complete before entering the office.
Step
1
of
4
25%
Name
*
First
Last
Do you have any of the following new or worsening symptoms or signs?
Fever or chills [Temp of 37.8 degrees C or 100 Degrees F or higher}]
Cough or barking cough (CROUP) [Continuous, more than usual, making a whistling noise when breathing]
Shortness of Breath [Out of breath, unable to breath deeply]
Decrease or loss of taste or smell [not related to Seasonal Allergies]
Muscle Aches/Joint Pain [Unusual, long-lasting]
Extreme Tiredness [Unusual, fatigue, lack of energy
If you have an existing health condition that gives you the symptoms you should not answer NO, unless the symptom is new, different or getting worse. Look for changes from your normal symptoms.
In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirement? )
No
Yes
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)
No
Yes
In the last 10 days, have you tested postivie on a rapid antigen test or a home-based self-testing kit? (if you have since tested negative on a lab-based PCR test, select no)
No
Yes
Consent
*
I agree to send this information for COVID-19 screening purposes
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