COVID-19 Coronavirus Screening Questionnaire Template
Looking for a paper-based survey data collection solution for your organization? Take a look at this covid-19 coronavirus screening questionnaire template for your upcoming research project.
Our templates come with well-designed questions that can be machine-read to recognize the checkmarks using optical mark recognition (OMR) technologies. Open text areas recognized with handwriting recognition (HWR) technologies allowing you to write handwritten text and automatically convert to a digitized format.
About this survey
This is a sample template to help doctors with reducing the heavy load of documenting the patient screening of Covid-19 virus. Keep in mind that this is incomplete survey and you should customize it to fit your research requirements.
Why this questionnaire?
With papersurvey.io platform you can quickly create a paper survey questionnaire that allows machine-reading the responses from the paper form.
Free for medical and research professionals
We offer our software for free to help stop this pandemic as soon as possible. Register for a free trial and reach out to firstname.lastname@example.org to obtain a free licence.
Feel free to contact us also if you need assistance to set this form up or to speed up your research and data collection.
Like this template? Use or customize this template to suit your needs.
List of questions in this template
- Adult Coronavirus (COVID-10) Screening Questionnaire
- 1. Headache
- 1. Asthma
- 2. Stuffy nose / runny nose
- 2. Diabetes type 1
- Please customize this form to suit your research requirements. The form will be read by a machine. Therefore it is important to use blue or black ballpoint pen and write clearly.
- Recipient's name
- 3. Sore throat
- 3. Diabetes type 2
- Recipient's name
- 4. Cough
- 4. Other lung disease
- Date of Birth
- 5. Shortness of breath
- 5. Severe overweight
- 6. Chest pain
- 6. Cardiovascular disease
- 7. Fever below 39.0
- 7. Kidney disease
- 8. Fever of 39.0 or higher
- Blood Type
- 8. Impaired immune system
- Patient's Temperature
- 9. Fever (not measured)
- 10. Convulsions
- Have you travelled outside of the Country in the last 14 days?
- Have you had contact with anyone that has travelled to an affected area in the last 14 days?
- 11. Other convulsions
- Do you have any allergies?
- 12. Joint pain
- During the past 12 months have you had swine influenza or other influenza-like illness?
- 13. Muscle pain
- If you had influenza, mark which symptoms you had and how many days they lasted.
- 14. Vomiting, diarrhoea
- 15. Ear infection
- Do you have one or more of the following diseases / conditions?
- 16. Pneumonia
- Have you had a flu vaccination within the last nine months?
- If you have visited a foreign country in the past three months, please indicate here
- Please describe how you are feeling Today
- Office-use only. *Please leave the following fields empty.*
- Covid-19 Test
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