Al-Zahra COVID-19 Questionnaire

Please note, you will be asked the following questions at time of registration for all Al-Zahra programs. Please note that children under 10 are currently not allowed to attend.

Do you currently exhibit any of the symptoms below?

  • *Severe difficulty breathing (e.g., struggling for each breath, speaking in single words)
  • Severe chest pain
  • Having a very hard time waking up
  • Feeling confused


  • *Lost consciousness
  • Shortness of breath at rest
  • Inability to lie down because of difficulty breathing
  • Chronic health conditions that you are having difficulty managing because of your current respiratory illness
  • Chills
  • *Painful swallowing
  • Stuffy nose
  • Headache
  • Muscle or joint ache
  • Feeling unwell, fatigue or severe exhaustion
  • *Nausea
  • Vomiting
  • Diarrhea or unexplained loss of appetite
  • Loss of sense of smell or taste
  • Conjunctivitis (pink eye)

In the past 10 days, have you experienced any of the following

  • Fever
  • New onset of cough or worsening of chronic cough
  • New or worsening shortness of breath
  • New or worsening difficulty breathing
  • Sore throat
  • Runny nose

In the past 14 days, did you return from travel outside of Canada, or did you have close contact with someone who is confirmed as having COVID-19?

  • Yes
  • No