COVID-19 Screening Questionnaire

1) Have you been in close contact with anyone who has had acute respiratory illness?YesNo

2) Have you travelled outside of Ontario within the last 14 days? YesNo

3) Have you been a confirmed case of COVID-19 or been in contact with a confirmed case of COVID-19?YesNo

4) Are you experiencing any of the following symptoms?YesNo

• Fever

• New onset of cough

• Worsening chronic cough

• Shortness of breath

• Difficulty breathing

• Sore throat

• Difficulty swallowing

• Decrease or loss of sense of taste or smell

• Chills

• Headaches

• Unexplained fatigue/malaise/muscle aches (myalgias)

• Nausea/vomiting, diarrhea, abdominal pain

• Pink eye (conjunctivitis)

• Runny nose/nasal congestion without other known cause

5) For individuals over 70 years old: are you experiencing any of the following symptoms: confusion, dizziness, a sudden change in the ability to function or worsening of chronic conditions? YesNo

Name:
Date:

If all questions are answered “no,” they are considered “COVID screen negative” and can enter the facility. If any question is answered “yes,” they are considered “COVID screen positive” and cannot enter the facility until they meet the criteria for “COVID screen negative.”