COVID-19 Screening Questionnaire Name * First Name Last Name Email * Subject * Please write: COVID-19 Screening complete Do you have a fever? * Yes No Do you have any of the following symptoms? New onset of cough Worsening chronic cough Sore throat Shortness of breath New loss or decrease in sense of taste or smell Headache Unexplained fatigue or malaise Difficulty swallowing Nausea/vomiting, diarrhea, abdominal pain Have you travelled or have had close contact with anyone who has travelled outside of Ontario in the past 14 days? * Yes No Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19? * Yes (if Yes, please stay home till you have a negative covid test) No (if no, the screening is complete) YOUR FORM HAS BEEN SUBMITTED. Thank you!
