Blackshop Restaurant Covid Screening Questions
Please fill out this form for each guest just before to entering the restaurant. Thank you!
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First Name *
Last Name *
Contact Telephone Number *
1. Are you currently experiencing any of the following symptoms? Symptoms should not be chronic or related to other known causes or conditions you already have. *
Yes
No
Fever and/or chills (temperature of 37.8 C or higher)
Difficulty Breathing and/or Shortness of breath
Cough or barking cough (croup)
Sore throat and/or or difficulty swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Digestive issues like nausea, vomiting, diarrhea, abdominal pain
Extreme tiredness or muscle aches
Headache - unusual, long lasting
If over 18 years old - Pink Eye (conjunctivitis)
If older - Falling down often
2. Is anyone you live with currently experiencing Covid-19 symptoms and/or waiting for test results *
Required
3. Have you or anyone you live with travelled outside of Canada in the past 14 days? (answer No if you are exempt from quarantine requirements) *
Required
4. In the last 14 days, have you or anyone you live with been identified as a "close contact" of someone who currently has COVID-19? *
Required
5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
Required
6. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *
Required
The Customer Information is being collected under the authority of s.2Health Protection and Promotion Act, s. 11(2) of the Municipal Act, Reopening Ontario (A Flexible Response to COVID-19) Act, 2020.V20210313 (You do not need to submit any answer)
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