COVID-19 Questionnaire for Staff & Clients
We are screening all staff and clients for potential risk of COVID-19 on a daily basis. Please complete the following information when booking an onsite service appointment.
Name (First and Last)
I am a:
Have you travelled outside of Canada in the last 14 days?
Within the last 14 days have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19?
Please click the boxes if you are experiencing any of the following symptoms. If you are not experiencing any symptoms, click None.
Difficulty breathing or shortness of breath
Cough that's new or worsening (continuous, more than usual)
Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Decrease or loss of sense of taste or smell
Pink eye (conjunctivitis)
Headache that is unusual or long lasting
Unexplained fatigue or muscle aches that are unusual or long lasting
Digestive issues like nausea/vomiting, diarrhea, abdominal pain
Send me a copy of my responses.
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