Covid-19 Pre-Screening Questionnaire Informed Consent Form

Covid-19 Pre-Screening Questionnaire

Pre-Screening Questionnaire
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. Fever and/or chills, temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher? *
b. Cough or barking cough (croup), continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)? *
c. Shortness of breath, out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)? *
d. Sore throat, not related to seasonal allergies, acid reflux, or other known causes or conditions you already have? *
e. Difficulty swallowing, painful swallowing (not related to other known causes or conditions you already have)? *
f. Runny or stuffy/congested nose, not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have? *
g. Decrease or loss of taste or smell, not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have? *
h. Pink eye, conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)? *
i. Headache, unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)? *
j. Digestive issues like nausea/vomiting, diarrhea, stomach pain, not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have? *
k. Muscle aches/joint pain, unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)? *
l. Extreme tiredness, unusual fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)? *
m. Falling down often? *
2. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.”

If the person got a COVID-19 vaccine in the last 48 hours and is experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *
3. In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *
4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

If public health has advised you that you do not need to self-isolate (for example, you are fully vaccinated or for another reason), select “No.” *
5. In the last 14 days, has anyone you live with:

travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?

or

been identified as a “close contact” of someone who currently has COVID-19 and been told to self-isolate by a doctor, healthcare provider, or public health unit?

If you are fully vaccinated, select “No.” *
6. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

This can be because of an outbreak or contact tracing. *
7. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?

If you have since tested negative on a lab-based PCR test, select "No." *
8. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.”

If you already went for a test and got a negative result, select “No.”
9. In the last 14 days, have you tested positive for Covid-19 or are you awaiting test results? *
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