• COVID19 Self Assessment Questionnaire

    This questionnaire is completed online.

  • 1. Are you experiencing any of the following:

    • Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
    • Severe chest pain
    • Having a very hard time waking up
    • Feeling confused Losing consciousness

  • 2. Are you experiencing any of the following:

    • Shortness of breath at rest
    • Inability to lie down because of difficulty breathing
    • Chronic health conditions that you are having difficulty managing because of difficulty breathing
    • High grade fever with rigors

  • 3. Are you experiencing any of the following:

    • Fever
    • Cough
    • Sneezing & Sneezing or other flu- like symptoms
    • Sore throat
    • Mild shortness of breath. 
    • Runny nose,

  • 4. Have you travelled to any countries within the last 14 days?

  • 5. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat)?

  • 6. Did you have close contact with a person who travelled in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?

  • 7. Are you above 65 years old or having underlying chronic condition including Diabetes, Hypertension, Chronic heart/ kidney/ liver disease or are you pregnant? Orare you a healthcare provider?

  • Should be Empty: