Alternate Covid Screening Questionnaire Alternate screening questionnaire for patients denying vaccination question. Covid Screening - Alternate Screening Questionnaire for Covid-19 Symptoms for patients denying vaccination question Name* First Last Phone*Email* Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?* Yes No Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?* Yes No Have you travelled outside of Canada in the past 14 days?* Yes No Do you have two (2) or more of the following symptoms:* Sore throat Hoarse Voice Difficulty swallowing Decreased or loss of sense of smell or taste Chills Headache Unexplained fatigue / malaise Diarrhea Abdominal pain Nausea Vomiting Pink eye (conjunctivitis) Runny nose Sneezing without other known cause Nasal congestion without other known cause Delirium Unexplained or Increased number of Falls Acute Functional Decline Worsening Chronic Conditions None of the Above Consent* I agree that this information is accurate and true.NameThis field is for validation purposes and should be left unchanged.
