COVID-19 Questionnaire

Name

Date

Please circle your answer to each of the following questions:

1. Do you currently have a fever, new onset of cough, worsening chronic cough. shortness of breath or difficulty breathing?

Yes No

2. Did you have close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days ?

Yes No

3. Have you been diagnosed with COVID-19 or have you had close contact with a confirmed case of COVID-19?

Yes No

4. Do you have any of the following symptoms:

5. *****Answer only if you are 70 yrs old or older

Do you have any of the following symptoms: delirium, unexplained or increased number of falls. acute functional decline, or worsening of chronic conditions?
Yes No