COVID-19 Screening Questionnaire
Name (Conducting Screening) *
Name (Participant) *
Date *
MM
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DD
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YYYY
Time *
Time
:
Venue *
Age *
Temperature *
Contact within 48hrs *
Have you been in contact with anyone with or suspected of having COVID-19 in the last 48 hours? Has anyone in your household had COVID-19 symptoms in the last 2 weeks? Have you been advised to self-isolate due to an infection within another setting, such as school?
Loss of smell or taste *
Have you had any loss of taste or smell?
New persistent cough *
Do you have a new persistent cough?
Underlying illness *
Do you have any underlying health conditions that would put you at further risk should you contract COVID-19? (Cardiovascular problems, High blood pressure, Diabetes, Chronic kidney or liver disease, Compromised immunity diseases, Obesity)
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