Covid 19 Screening Questions

d066 Covid-19
Name
Name
First
Middle
Last
Do you have any of the following symptoms?
Fever and/ or chills
Cough or barking cough
Shortnes of breath
Decrease or loss of smell or taste
Fatigue, lethargy, muscle aches, joint pain (for adults > 18 years old)
Nausea, vomiting, and/or diarrhea (for children < 18 years old)
3. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing
5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No.”
6. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?
7. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
8. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
9. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate?
10. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
Adults: (≥18 years old): fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of taste or smell; tiredness; muscle aches. If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is only experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”