Blackshop Restaurant Covid Screening Questions
Please fill out this form for each guest just before to entering the restaurant. Thank you!
Sign in to Google to save your progress. Learn more
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. *
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 *
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) *
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? *
5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
6. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *
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)
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy