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.


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 platform you can quickly create a paper survey questionnaire that allows machine-reading the responses from the paper form.

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We offer our software for free to help stop this pandemic as soon as possible. Register for a free trial and reach out to 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.

Questions in this survey: 44, Language: English

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List of questions in this template

  1. Adult Coronavirus (COVID-10) Screening Questionnaire
  2. 1. Headache
  3. 1. Asthma
  4. 2. Stuffy nose / runny nose
  5. 2. Diabetes type 1
  6. 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.
  7. Recipient's name
  8. 3. Sore throat
  9. 3. Diabetes type 2
  10. Recipient's name
  11. 4. Cough
  12. 4. Other lung disease
  13. Date of Birth
  14. 5. Shortness of breath
  15. 5. Severe overweight
  16. 6. Chest pain
  17. 6. Cardiovascular disease
  18. Age
  19. 7. Fever below 39.0
  20. 7. Kidney disease
  21. Ethnicity
  22. 8. Fever of 39.0 or higher
  23. Blood Type
  24. 8. Impaired immune system
  25. Patient's Temperature
  26. 9. Fever (not measured)
  27. 10. Convulsions
  28. Have you travelled outside of the Country in the last 14 days?
  29. Have you had contact with anyone that has travelled to an affected area in the last 14 days?
  30. 11. Other convulsions
  31. Do you have any allergies?
  32. 12. Joint pain
  33. During the past 12 months have you had swine influenza or other influenza-like illness?
  34. 13. Muscle pain
  35. If you had influenza, mark which symptoms you had and how many days they lasted.
  36. 14. Vomiting, diarrhoea
  37. 15. Ear infection
  38. Do you have one or more of the following diseases / conditions?
  39. 16. Pneumonia
  40. Have you had a flu vaccination within the last nine months?
  41. If you have visited a foreign country in the past three months, please indicate here
  42. Please describe how you are feeling Today
  43. Office-use only. *Please leave the following fields empty.*
  44. Covid-19 Test

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