COVID-19 Pre-Screening Questionnaire

Patient Information

Patient's first name

Patient's last name

Are you completing this form on behalf of someone else?

Yes No

What is your name?

What is your relationship to the patient?

Are you currently under the direction of Public Health to self-isolate or quarantine?

Yes No

Are you a close contact of someone who has tested positive for COVID 19 in the last 10 days?

Yes No

Are you currently experiencing any of the following symptoms?

Fever or chills

Yes No

New or worsening cough

Yes No

New or worsening shortness of breath or difficulty breathing

Yes No

Sore throat or painful swallowing

Yes No

Stuffy nose or runny nose

Yes No

Loss of smell or taste?

Yes No

Feeling unwell, fatigue or severe exhaustion?

Yes No

Nausea, vomitting, diarrhea or unexplained loss or appetite?

Yes No

Conjunctivitis (pink eye)?

Yes No