Covid-19 Pre-Screening Questionnaire

Your Name *

Your Email *

Date Filled Out *

1. Are you currently experiencing any of these symptoms? Note any/all that are new, worsening, and not related to other known causes or conditions you already have.
a. Runny nose/congestionb. Coughc. Headached. Sore throate. Fever
2. Is anyone in your household currently experiencing any of the above-mentioned COVID-19 symptoms?
NoYes
3. In the last 5 days, have you or anyone in your household been in “close contact” with someone who has exhibited the above-mentioned COVID-19 symptoms? “Close contact” refers to being in the same close space for more than 15mins without the use of PPE.
NoYes
4. In the last 5 days, have you or anyone in your household travelled outside of Canada?
NoYes
5. Have you been previously infected by COVID-19 in the last 90 days?
NoYes
6. Have you been vaccinated against COVID-19? As a health care provider, I am allowed to ask this question.
NoYesPrefer not to answer