Covid-19 Health Screening Questionnaire Full Name (required) Email (required) Do you or someone in your family has any of the following symptoms: severe difficulty breathing (e.g., struggling for each breath, speaking in single words), chest pain, confusion, extreme drowsiness or loss of consciousness? YesNo Do you or someone in your family has shortness of breath at rest or difficulty breathing when lying down? YesNo Do you or someone in your family has a new onset of any of the following symptoms: fever, cough, sore throat, shortness of breath and if the patient is an infant, poor feeding and lethargy? YesNo Do you or someone in your family has a new onset of 2 or more of any of the following symptoms: runny nose, muscle aches, fatigue, loss of taste or smell, headache, hoarse voice or nausea, vomiting or diarrhea for more than 24 hours? YesNo Have you or one of your family members been in contact in the last 14 days with someone that is confirmed to have COVID-19? YesNo Have you or one of your family members had laboratory exposure while working directly with specimens known to contain COVID-19? YesNo Have you or one of your family members been in a setting in the last 14 days that has been identified as a risk for acquiring COVID-19, such as on a flight, at a workplace or an event? YesNo Have you or one of your family members travelled outside of BC in the last 14 days? YesNo Your browser does not support JavaScript!. Please enable javascript in your browser in order to get form work properly.
