COVID-19 Pre-Screening & Contact Tracing Form
HOW ARE YOU FEELING TODAY?

This form MUST be completed within 24 hours of your class and prior to entering the studio.

* Fully vaccinated means 14 days or more after getting a second dose of a two dose COVID-19 vaccine series or one dose of a single dose series.
**Anyone who is sick or has any symptoms of illness should stay home and seek assessment from their health care provider if needed.

Link to Federal Quarantine Requirements
https://travel.gc.ca/travel-covid/travel-restrictions/isolation#exemptions

Thank you!
iFreeStyle.ca
Sign in to Google to save your progress. Learn more
Full name *
Email *
Phone number *
Do you have any of the following new or worsening symptoms: fever & chills, cough, trouble breathing, decrease or loss of taste or smell, tired, sore muscles or joints. If the symptom is new, different or getting worse, select “Yes” and stay home, get tested or contact a health care provider. If you have a health condition diagnosed by a health care provider that gives you the symptom, select “No”. *
Does anyone in your household have one or more of the above symptoms and/or are waiting for test results after experiencing symptoms? If you are fully vaccinated* or have tested positive for COVID-19 in the last 90 days and been cleared, select “No”. *
Have you been notified as a close contact of someone with COVID-19 or been told o stay home and self-isolate? If you are fully vaccinated* or have tested positive for COVID-19 in the last 90 days and been cleared or public health has told you that you do not have to self-isolate, select “No”. *
In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.” *
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Weebly Email Service. Report Abuse