Patient COVID-19 Self Screening Questionnaire

Patient COVID-19 Self Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT enter the office.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify our receptionists.

1) Have you had any of the following symptoms in the last 24 hours? *

Yes

Cough

Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

Yes

Fever (usually 38°C or higher)

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come into work. You should:
- Self- quarantine for at least 14 days from the date on which you first experienced any of the above symptoms ; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you: *

Yes

Been in contact with someone who was diagnosed with COVID-19?

Been in close contact with someone who had COVID-19 symptoms ?

Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.
Signature or Patient's Parent Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty: