COVID 19 Screening & Contact Tracing Form
Please fill out the form below with accurate information before entering our showroom.
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Full Name (Please include Company Name if applicable) *
Phone Number *
Email Address *
Date *
MM
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DD
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Are you currently experiencing one or more of the following symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions? (For Individuals over 18 years old) *
Yes
No
Fever and/or Chills (Temperature of 37.8 Degrees Celius/100 Degrees Fahrenheit or higher
Cough or Barking Cough (Not related to Asthma, COPD or other conditions)
Shortness of breath (Not related to Asthma, or other known causes/conditions)
Sore throat (Not related to seasonal allegeries, acid reflux, or other known causes/conditions)
Difficulty swallowing (Painful swallowing not related to known causes/conditions)
Decreased or loss of smell/taste (Not related to seasonal allegeries, neurological disorders, or other known causes/conditions)
Nausea/Vomiting/Diarrhea/Stomach Pain (Not related to known causes/conditions)
Sore Muscles (Unusual, long lasting, not related to known causes/conditions)
Exhaustion/Extreme Tiredness (Unusual, fatigue, lack of energy not related to a known causes/conditions)
Headache (Unusual, long lasting, not related to other known causes/conditions)
Pink Eye (Not related to reoccurring styes or other known casues or conditions you already have)
Runny or stuffy/congested nose (Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have)
Falling Down (For Older People)
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
Has a Doctor, Health Care Provider or Public Health Unit told you that you should currently be isolating (Staying at home)? *
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID - 19 ? *
In the last 14 days, have you received a COVID Alert Exposure Notification on your cell phone? (If you already went for a test and received a negative result, select "No") *
Have you or anyone in your household travelled outside of Canada in the past 14 days? (If you are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, Select "No" *
Please select one of the option below based on your answers above. *
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