Health Screening Form (Staff/Visitor) Hitherfield School COVID Screening QuestionsStaff/Visitor Name*Temperature Unit:*Degrees CelsiusDegrees FahrenheitTemperature*The temperature should be in Degrees CelsiusTemperature*The temperature should be in Degrees FahrenheitHave you and / or anyone in the household been diagnosed or is awaiting test results / under investigation for COVID-19 in the past 14 days?*YESNOHave you and/ or anyone in the household had close contact with a known or suspected case of COVID-19 in the past 14 days?*YESNOHave you and / or anyone in the household travelled outside of Canada in the last 14 days?*YESNOHave you and / or anyone in the household been informed by public health or another authority to self-isolate or quarantine in the past 14 days?*YESNOIn the past 48 hours:1. Have you had any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.Fever and/or chills*(temperature of 99.5 degrees Fahrenheit or greater)YESNOCough*(more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing) and not related to other known causes or conditions (e.g asthma, reactive airway)YESNOShortness of Breath*(dyspnea, out of breath, unable to breathe deeply, wheeze that is worse than usual if chronically short of breath). Not related to other known causes or conditions (e.g., asthma)YESNODecrease or loss of smell or taste*Decrease or loss of smell or taste (new olfactory or taste disorder). Not related to other known causes or conditions (e.g., nasal polyps, allergies, neurological disorders)YESNO2. Do you have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.Sore throat*(painful swallowing or difficulty swallowing). Not related to other known causes or conditions (e.g., post nasal drip, gastro-esophageal reflux)YESNOStuffy nose and/or runny nose* Not related to other known causes or conditions (e.g., seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways) YESNOHeadache* that is new and persistent, unusual, unexplained, or long-lasting and not related to other known causes or conditions (e.g., tension-type headaches, chronic migraines) YESNONausea, vomiting and/or diarrhea* Not related to other known causes or conditions (e.g., transient vomiting due to anxiety, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication) YESNOFatigue, lethargy, muscle aches or malaise* (general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained. Not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia) YESNOStaff/Visitor Signature*Staff/Visitor Email* Date A yes to any of the above means the staff member/visitor must stay home, self isolate, and call Telehealth or their health care provider to find out if they need a test.
