COVID Screening Questionnaire

Name*

First Last

Date*

Today's office location:*

South (2412 Kaladar Avenue)
West (570-1600 Carling Avenue)
Kemptville (A3-3000 County Road 43)
Stittsville (2017 Carp Road)

Have you travelled outside of Canada in the last 14 days and have been told to quarantine (as per the federal quarantine requirements)?*

Yes
No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating or staying at home? This can be because of an outbreak, contact tracing, or after testing positive on a rapid antigen test.*

Yes
No

Choose any/all that are new or worsening, and not related to other known causes or conditions you already have. In the last 10 days, have you had any of the following most common symptoms of COVID-19? If you have since tested negative and have not had symptoms for 24 hours, answer "No".*

Select all that apply.

Fever and/or chills (temperature of 37.8 degrees Celsius/100 degree Fahrenheit or higher)
Cough (examples: barking cough (croup), continuous cough, coughing more than usual, or making a whistling noise when breathing that is not related to asthma, post-infectious reactive airways, or other known causes or conditions you already have)
Shortness of breath (out of breath, unable to breathe deeply (not related to asthma))
Decrease or loss of taste or smell (not related to seasonal allergies, neurological disorders)
Muscle aches and pains (that is unexplained or unusual (not related to sudden injury, fibromyalgia, or receiving a COVID-19 vaccine in the past 48 hours)
Extreme tiredness, lack of energy or feeling unwell (that is unusual or unexpected (not related to depression, insomnia, thyroid dysfunction, or receiving a COVID-19 vaccine in the past 48 hours))
No symptoms

Do you have any of the following other symptoms of COVID-19? Choose any/all that are new or worsening, and not related to other known causes or conditions you already have.*

Select all that apply.

Sore throat (painful swallowing or difficulty swallowing (not related to seasonal allergies, acid reflux, post nasal drip))
Runny or stuffy/congested nose (not related to seasonal allergies, being outside in cold weather, chronic sinusitis unchanged from baseline)
Conjunctivitis (pink eye) (not related to blepharitis, recurrent styes)
Decreased or lack of appetite (not related to anxiety, constipation)
Abdominal pain (persistent and ongoing (not related to menstrual cramps, gastroesophageal reflux disease))
Headache (new and persistent, unusual, unexplained, or long-lasting (not related to tension-type headaches, chronic migraines, receiving a COVID-19 vaccine in the past 48 hours))
No symptoms

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, answer "No".*

Yes
No

CAPTCHA

COVID-19 Daily Screening Questionnaire