Daily COVID-19 Screening
To be filled in the line up or just prior to Temperature Check up. DO NOT SUBMIT BEFORE TEMP Check. By Filling this questionnaire I consent to have my temperature verified by a Health Officer ( either with non contact or oral thermometer )
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*
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TIme
*
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Minute
matin
après-midi
AM/PM Option
Identification
*
name
Surname
Email
exemple@exemple.com
Questions
1. Do you have a fever or a feeling of fever (chills)?
*
YES
NO
2. Do you have a cough?
*
YES
NO
3. Do you have difficulty breathing or chest pain?
*
YES
NO
4. Have you lost your sense of smell or taste?
*
YES
NO
5. Do you have any other symptoms that concern you? ( muscle aches, sore throat, headache, etc. ) If yes, please specify:
N/A
Did you take any fever medication in the last 6 hours ? ( Tylenol, Advil, etc.)
YES
NO
Temperature Check
To be filled by Medic
Body Temperature
*
Celsius
Type
Oral
Contact Free
Validation
Name of medical personnel who validated the questionnaire
*
Stephanie Singer
Chelsea Benson
Adam Viscount
Sels-Assessment
OTHER
SUBMIT
Should be Empty: