Relationship Questionnaire During Covid-19

Can I Break the Bubble with You? 

Because I do want to see you but damn, you better not be seeing anyone else

This questionnaire is designed to help you decide if you want to see a loved one during the Covid-19 global pandemic. These questions will help you assess the risk of a visit and whether or not you share the same definition of “physical distancing”. Please share with your friends, family, roommates or anyone you think may find this useful. There is a PNG image at the bottom of this page for easy sharing over social media. Enjoy!

The questions:

  1. Are you experiencing symptoms of (check all that apply)
    1. Coughing
    2. Trouble Breathing
    3. Fever
  2. Have you travelled anywhere within the last 14 days?
    1. If so, where?
  3. Are you practicing physical distancing? How?
  4. Do you live with anyone? 
    1. If yes, where do they work? 
    2. How are they practicing physical distancing?
  5. Please select all the behaviours you are following
    1. Maintaining 2 m distance from all other people who you do not live with
    2. Washing your hands frequently, and especially before/after eating and going to the bathroom
  6. Are you leaving home to go shopping?
    1. What are you shopping for when you leave (eg. only the essentials or otherwise?)
    2. How often are you going shopping?
    3. What precautions are you taking when you go shopping? (eg. gloves, face mask, etc.)
  7. Have you visited anyone’s home in the last 14 days?
  8. Have you hugged, kissed, or touched anyone other than the people that you live within the last 14 days?
  9. If the answers to the questions above anytime during this Covid-19 outbreak change, will you tell me? How?

Are there any questions that I missed? Do you find this helpful? Please let me know by leaving a reply in the comment box below. Many thanks!

Save this image to your phone and share it on social media!
Covid 19 Relationship Questionnaire


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