Covid-19 Screening Questionnaire

Questionnaire for COVID-19 screening provided by Igbinedion University is below shown. Kindly provide the required information in the questionnaire.

[A] Biodata.

1. Name *

First

Middle

Last

2. AGE

• Less than 18 years
• 18 to 64 years
• 65 years and above

3. SEX

• Male
• Female

4a. STUDENTS

Department:……………………………………………………………………
Level:……………………………………………………………………………………

4b. STAFF

Department:……………………………………………………………………

• Academic
• Non-Academic
• Senior
• Junior

[B] SIGNS, SYMPTOMATOLOGY, TRAVEL AND MEDICAL HISTORY:

5. Do you currently have any of the following signs and symptoms?

• Fever, chills or sweating
• Aching through the body (muscle and joint pains)
• Cough
• Shortness of breath or difficulty in breathing
• Sore throat
• Loss of sense of smell
• Loss of taste sensation
• Vomiting
• Diarrhea

6. Have you had any of these in the last two weeks?

• Fever, chills or sweating
• Aching through the body (muscle and joint pains)
• Cough
• Shortness of breath or difficulty in breathing
• Sore throat
• Loss of sense of smell
• Loss of taste sensation
• Vomiting
• Diarrhea

7. Have you travelled internationally in the last 2weeks to 6months?

• Yes
• No

8. Have you travelled domestically to area endemic for COVID-19 in the last 2weeks?

• Yes
• No

9. Have you been residing in a place spreading with COVID-19 in the past 2weeks?

• Yes
• No

10. In the last 2weeks what has been your exposure to someone confirmed with COVID-19?

I live with someone who has covid-19YesNo

I’ve had touch with someone who has COVID-19 (I was exposed within 2metres of someone sick coughing and sneezing and spent at least 10 minutes within the exposure)YesNo

I’ve been near someone who has COVID-19 (I was at least 2metres away and was not exposed to coughing or sneezing)YesNo

I’ve been near someone who has COVID-19 (I was at least 2metres away and was not exposed to coughing or sneezing) (copy)YesNo

11. Have you been tested for COVID-19?

• Yes
• No

12. Have you been confirmed and diagnosed with COVID-19?

• Yes
• No

13. If yes to question 12, how many weeks ago?.............................................................................

14. Have you been treated for COVID-19?

• Yes
• No

15. What treatment modality did you utilize?

Orthodox treatment at a medical and isolation facility.

• Yes
• No

Orthodox treatment at home isolation.

• Yes
• No

Unorthodox and home remedies like fruits and herbs at home isolation.

• Yes
• No

I did not use any remedy or drugs, I just got better.

• Yes
• No

16. Have you been confirmed negative for COVID-19?

• Yes
• No

17. Do you have any of these medical conditions? Please tick as much as it applies to you?

Hypertension.

• Yes
• No

Diabetes.

• Yes
• No

Heart failure.

• Yes
• No

Liver diseases.

• Yes
• No

Kidney disease.

• Yes
• No

Have had Dialysis.

• Yes
• No

Lung diseases like Asthma, bronchitis and tuberculosis.

• Yes
• No

Retroviral diseases like HIV.

• Yes
• No

Sickle cell disease.

• Yes
• No

Cancers.

• Yes
• No

Obesity.

• Yes
• No

Pregnancy.

• Yes
• No

None of the above.

• Yes
• No

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