COVID-19 Questionnaire

Dear Patient,

In accordance with CDSBC's Infection Prevention and Control Guidelines and BCDA's Exposure Control Plan, please indicate "YES" or "NO" to the following questions and sign and date below:

Do you have any of the following symptoms?

Have you traveled outside of Canada within the last 14 days?

Yes

Have you had any close contact or have you been in isolation with a suspected case of COVID-19 in the last 14 days?

Yes

Have you had any other potentially relevant exposure such as close contact with someone who was ill and/or had traveled outside of Canada within 14 days?

Yes

Has there been any changes to your medical history?

Yes

If you answered "YES", please provide details:

Patient Name

Date

Patient Signature (drag mouse / finger / stylus to sign)

Reset Signature

Dry Cough?	Yes	No
Sore throat or painful swallowing?	Yes	No
Shortness of breath?	Yes	No
Fever?	Yes	No
Runny nose, sneezing, post-nasal drip, loss of smell (anosmia) with or without fever?	Yes	No
Loss of appetite?	Yes	No
Chills?	Yes	No
Muscle aches?	Yes	No
Headache?	Yes	No
Fatigue?	Yes	No