| COVID-19 Screening Questionnaire

Name *

Date *

Time

Practitioner *

Part A: In the past 24 hours, have you experienced:

Fever or Chills

Cough

Difficulty breathing or shortness of breath

Sore throat or trouble shallowing

Runny or stuffy nose

Decrease or loss of taste or smell

Nausea, vomiting or diarrhea

Not feeling well, extreme tiredness or sore muscle

Pink eye or headache

Part B: Does anyone in your household have one or more of the following symptoms?

Yes

No

Have you been notified as a close contact of someone with Covid-19 or been told to stay at home and self-isolate?

Yes

No

In the last 14 days, have you or anyone in your household travelled outside Canada?

Yes

No