COVID-19 Screening Questionnaire Name Date Required Screening Questions 1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Fever or chills YesNo Difficulty breathing of shortness of breath YesNo Cough YesNo Sore throat, trouble swallowing YesNo Runny nose, stuffy nose or nasal congestion YesNo Decrease or loss of smell or taste YesNo Nausea, vomiting, diarrhea, abdominal pain YesNo Not feeling well, extreme tiredness, sore muscles YesNo 2. Have you traveled outside of Canada in the past 14 days? YesNo 3. Have you had close contact with a confirmed or probable case of COVID-19? YesNo
