Triage Screening Questionnaire Parent/Guardian Name Address Phone Patient Name Place of employment Presenting complaint (s) of Child/ Reason for Visit PLEASE INDICATE/IDENTIFY THE PRESENCE OF ANY OF THE FOLLOWING SYMPTOMS IN THE PAST 14 DAYS. MAJOR/MINOR CRITERIA (Please check boxes or type information) Cough (Productive/Non Productive) Fever (Subjective/Objective) Shortness of Breath Chest Pain Chest Pain (Sharp, stabbing or worsen with deep breathing or cough) Low energy/ Fatigue Headache Loss of taste Loss of smell Muscle pain/body ache/joint pain Nausea/Vomiting Sore throat Runny nose or congestion Diarrhea Did you have contact with a person KNOWN or SUSPECTED of having COVID-19 (YES or NO)? Were you previously tested for COVID-19 (PCR, RAPID-IGG/IGM) Yes of No If yes which test did you take and when? Results of the test performed (if applicable) +VE, -VE, Unknown or N/A Were you admitted and treated for COVID-19 (Yes or NO - PLEASE PROVIDE THE DATE) Deemed recovered from COVID-19 (Yes or NO - PLEASE PROVIDE THE DATE) Have you traveled in the past 14 days? (Yes or No) If traveled from another country (PLEASE INDICATE) If traveled from a family island (PLEASE INDICATE) Email Date Send
