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Covid-19 Questionnaire for VISITORS

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Contact Information
Question 1 Definitions:

Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)
Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath
Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease or loss of taste or smell
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Muscle aches/joint pain
Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Fatigue
Unusual, tiredness, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours), depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have). If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”

Sore Throat
Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

Runny or stuffy/congested nose
Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.

Headache
New, unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have. If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing a headache that only began after vaccination, select “No.”

Nausea, vomiting and/or diarrhea
Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have

1. Are you currently experiencing any of these symptoms?

Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.


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