COVID-19 SCREENING QUESTIONNAIRE
To screen for COVID-19 symptoms. If client is experiencing any of the following symptoms listed below, please postpone and reschedule visit at least 2 weeks later.
Full Name *
1a. Are you or anyone in the household currently experiencing any of these symptoms: Fever and/or chills? *
Temperature of 37.8℃ /100℉ or higher
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1b. Are you or anyone in the household currently experiencing any of these symptoms: Cough or barking cough? *
Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways)
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1c. Are you or anyone in the household currently experiencing any of these symptoms: Shortness of breath? *
Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)
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1d. Are you or anyone in the household currently experiencing any of these symptoms: Decrease or loss of smell or taste? *
Not related to other known causes or conditions (for example, allergies, neurological disorders)
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2a. Are you or anyone in the household currently experiencing any of these symptoms: Sore throat or difficulty swallowing? *
Painful swallowing, not related to other known causes or conditions (for example, seasonal allergies, acid reflux)
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2b. Are you or anyone in the household currently experiencing any of these symptoms: Runny or stuffy / congested nose? *
Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)
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2c. Are you or anyone in the household currently experiencing any of these symptoms: Headache that’s unusual or long lasting? *
Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)
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2d. Are you or anyone in the household currently experiencing any of these symptoms: Nausea, vomiting and / or diarrhea? *
Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps)
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2e. Are you or anyone in the household currently experiencing any of these symptoms: Extreme tiredness that is unusual or muscle aches? *
Fatigue, lack of energy, poor feeding in infants, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction, sudden injury)
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3. Have you or anyone in the household travelled outside of Canada in the last 14 days? *
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4. In the last 14 days, has a public health unit identified you or anyone in the household as a close contact of someone who currently has COVID-19? *
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5. Has a doctor, health care provider, or public health unit told you or anyone in the household that they should currently be isolating (staying at home)? *
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6. In the last 14 days, have you or anyone in the household received a COVID Alert exposure notification on their cell phone? *
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