RSV Screening Questionnaire Form
Please answer the following questions to help us screen for RSV-related symptoms and exposure risk. This form does not collect sensitive or financial information.
What is your age group?
*
Please Select
Under 1 year
1–4 years
5–17 years
18–64 years
65 years or older
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Cough
Runny nose or congestion
Fever or chills
Sore throat
Shortness of breath or wheezing
No symptoms
When did your symptoms begin?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had close contact with anyone diagnosed with RSV in the past 14 days?
*
Yes
No
Not sure
Have you traveled outside your local area in the past 14 days?
Yes
No
Do you have any chronic health conditions (such as asthma, diabetes, or heart disease)?
Yes
No
Prefer not to say
Are you currently pregnant or caring for an infant under 6 months old?
Yes
No
Not applicable
Have you received any vaccination for RSV?
Yes
No
Not sure
Are you currently taking any medication for your symptoms?
Yes
No
Is there anything else you would like to share about your symptoms or recent exposures?
Submit Screening
Should be Empty: