COVID-19 Screening questions

Name:  _________________________             Date:  _____________

Screening Questions                                                 

1. Do you have any of the following new or worsening symptoms or signs? 

New or worsening Cough	Yes	No
Shortness of Breath	Yes	No
Sore Throat	Yes	No
Runny Nose, sneezing or nasal Congestion	Yes	No

Hoarse voice	Yes	No
Difficulty Swallowing	Yes	No
New Smell or taste disorder(s)	Yes	No
Nausea / Vomiting, diarrhea, abdominal pain	Yes	No
Unexpected fatigue/malaise	Yes	No
Chills	Yes	No
Headache	Yes	No

2. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days? 

   Yes                                  No

3. Do you have a fever? 

  Yes                                    No

4. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19? 

  Yes – go to question 5       No – screening complete

5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19? 

  Yes                                    No

Analysis of Results to Screening Questions:

ABLE TO ENTER THE CLINIC	NOT PERMITTED TO ENTER THE CLINIC
AnswersNO to ALL Questions’ 1-4 Answers Yes to Question 4 and 5, and does not have a fever	Answers Yes to ANY Questions’ 1-3 Answers Yes to Question 4, and No to Question 5

Administered by:  ______________________________    Date:  ______________