top of page

Covid-19 Health Questionnaire

Please read each question carefully and answer the questions with the correct answer that applies. 

​

Daily monitoring for potential COVID-19 symptoms is important to track your current health status. If you experience new symptoms, consider seeing your healthcare provider or getting a test for COVID-19, especially where you may have had potential exposures to COVID-19.  

 

You should also monitor your health and consider consulting your primary care physician after testing positive for COVID-19. 

1 

 Have you experienced any of the following COVID -19 symptoms in the last 48hrs?

• Fever or Chills • Cough • Shortness of Breath or Difficulty Breathing • Fatigue • Muscle or Body Aches • Headache • Recent Loss Of Taste/Smell • Sore Throat • Congestion • Runny Nose   • Nausea/Vomiting • Diarrhea

​

                                                      YES                  NO

2

Have you tested positive for COVID-19 in the past 10 days?

                                                    YES                  NO

3

Are you currently awaiting results from a COVID-19 test? 

                                                    YES                  NO

4

Have you been diagnosed with COVID -19 by a licensed doctor in the past 10 days?

                                                    YES                  NO

5

Have you been advised of a COVID-19 contact through trace?

                                                    YES                  NO

Let's Work Together

Answering yes to any of the Health Questionnaire Test questions indicates possible Covid-19 exposure. Please consult with a physician or medical facility for further testing.

bottom of page