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    COVID

    Uploaded by

    Margarett Geronimo
    This document is a COVID-19 self-screening questionnaire that collects an individual's name, age, contact information, address, and answers to questions about symptoms experienced in the last 72 hours and risk factors in the last 14 days. The questionnaire asks if the individual has experienced symptoms like cough, fever, headache, sore throat, difficulty breathing, loss of smell or taste, diarrhea, or muscle pain. It also screens for contact with a COVID-19 positive person, close contact with someone exhibiting symptoms, international travel, or if they have been swabbed or are awaiting swab results.

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    COVID

    Uploaded by

    Margarett Geronimo
    9 views2 pages
    This document is a COVID-19 self-screening questionnaire that collects an individual's name, age, contact information, address, and answers to questions about symptoms experienced in the last 72 hours and risk factors in the last 14 days. The questionnaire asks if the individual has experienced symptoms like cough, fever, headache, sore throat, difficulty breathing, loss of smell or taste, diarrhea, or muscle pain. It also screens for contact with a COVID-19 positive person, close contact with someone exhibiting symptoms, international travel, or if they have been swabbed or are awaiting swab results.

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    This document is a COVID-19 self-screening questionnaire that collects an individual's name, age, contact information, address, and answers to questions about symptoms experienced in the last 72 hours and risk factors in the last 14 days. The questionnaire asks if the individual has experienced symptoms like cough, fever, headache, sore throat, difficulty breathing, loss of smell or taste, diarrhea, or muscle pain. It also screens for contact with a COVID-19 positive person, close contact with someone exhibiting symptoms, international travel, or if they have been swabbed or are awaiting swab results.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    9 views2 pages

    COVID

    Uploaded by

    Margarett Geronimo
    This document is a COVID-19 self-screening questionnaire that collects an individual's name, age, contact information, address, and answers to questions about symptoms experienced in the last 72 hours and risk factors in the last 14 days. The questionnaire asks if the individual has experienced symptoms like cough, fever, headache, sore throat, difficulty breathing, loss of smell or taste, diarrhea, or muscle pain. It also screens for contact with a COVID-19 positive person, close contact with someone exhibiting symptoms, international travel, or if they have been swabbed or are awaiting swab results.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    COVID-19 SELF SCREENING

    QUESTIONNAIRE COVID-19 SELF SCREENING


    QUESTIONNAIRE
    FULL NAME: _______________________________________________________
    FULL NAME: _______________________________________________________
    AGE: _____ CONTACT NUMBER: ____________ DATE/TIME: ________________
    AGE: _____ CONTACT NUMBER: ____________ DATE/TIME: ________________
    ADDRESS:_________________________________________________________
    ADDRESS:_________________________________________________________
    1. Have you had any of the following symptoms in the last 72
    1. Have you had any of the following symptoms in the last 72
    hours (3 days)?
    hours (3 days)?
    YES NO
    Cough (Ubo) YES NO
    Fever (Lagnat) Cough (Ubo)
    Headache (pananakit ng ulo) Fever (Lagnat)
    Soar Throat (pananakit ng Headache (pananakit ng ulo)
    Lalamunan) Soar Throat (pananakit ng
    Difficulty of Breathing (Hirap sap Lalamunan)
    ag hinga) Difficulty of Breathing (Hirap sap
    Loss of sense of Smell (Kawaalan ag hinga)
    ng Pang-amoy) Loss of sense of Smell (Kawaalan
    Loss of sense of Taste (Kawaalan ng Pang-amoy)
    ng Pang-Lasa) Loss of sense of Taste (Kawaalan
    Diarrhea (Sirang pag-dumi) ng Pang-Lasa)
    Muscle Pain (Pananakit ng Diarrhea (Sirang pag-dumi)
    Katawan) Muscle Pain (Pananakit ng
    Katawan)
    2. In the last 14 days have you:
    YES NO 2. In the last 14 days have you:
    Been in Contact with YES NO
    someone who was Been in Contact with
    diagnosed someone who was
    with COVID-19? diagnosed
    Been in close contact with with COVID-19?
    someone who had Been in close contact with
    COVID-19 symptoms? someone who had
    Traveled internationally? COVID-19 symptoms?
    Been SWAB or waiting for Traveled internationally?
    SWAB result? Been SWAB or waiting for
    SWAB result?

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