COVID-19 Screening Questions
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Have you travelled outside of Canada in the past 14 days?
*
Yes
No
Have you tested postitive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
*
Yes
No
Please indicate if you have any of the following symptoms?
*
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chill
Headaches
Unexplained fatigue/malaise/muscle aches
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose or nasal confestion without other known cause
No Symptoms
If you are 70 years of age or older, are you experiencing any of the following symptoms?
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
No Symptoms
Signature
*
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