Covid Screening Questionnaire Covid Screening Screening Questionnaire for Covid-19 Symptoms that must be filled out before each appointment. Name* First Last Phone*Email* 1. Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?* Yes No 2. Have you had any close contact with anyone with acute respiratory illness OR travelled outside of Canada in the past 14 days?* Yes No 3. Do you have a confirmed case of COVID-19 OR had close contact with a confirmed case of COVID-19?* Yes No Do you have any of the following symptoms? (Check all that apply)* Sore throat Hoarse Voice Difficulty swallowing Decreased or loss 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) None of the above If you are 65 years of age or older, are you experiencing any of the following? Delirium Unexplained or increased number of falls Acute functional decline or 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.
