Covid-19 Pre-Screening Questionnaire Informed Consent Form

Covid-19 Pre-Screening Questionnaire

Pre-Screening Questionnaire
1. Do you/have you had a fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing within the past 14 days? *
2. Have you travelled outside of Canada or Ontario within the past 14 days? *
3. Have you had close contact with anyone with acute respiratory illness or anyone who has travelled outside of Canada or Ontario within the past 14 days? *
4. Have you been confirmed positive for Covid-19 or have you been in close contact with anyone who has tested positive for Covid-19? *
5. Are you currently waiting for Covid-19 test results? *
6. Are you immuno-compromised? *
7. Do you have 2 or more of the following symptoms? *
  • Sore throat
  • Runny nose/sneezing/nasal congestion
  • Hoarse voice
  • Difficulty swallowing
  • Decrease or loss of smell and/or taste
  • Chills
  • Headache
  • Unexplained fatigue
  • Diarrhea
  • Abdominal pain
  • Nausea and/or vommiting
8. Do you have any underlying health issues? Ie; diabetes, heart disease, high blood pressure, kidney disease, asthma, COPD (chronic obstructive pulmonary disease) *
9. Have you had any recent surgeries or injuries? *
10. Have you experienced any acute functional declines, falls, worsening of current or chronic conditions? *
11. Do you work in a healthcare environment and/or are exposed to people who are ill? *
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