COVID19 Screening Form Visitor
Full Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Email
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example@example.com
Company
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Who are you visiting?
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DateTime
Are you currently experiencing any of these? Call 911 if you are
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Severe difficulty breathing (Struggling for each breath, can only speak in single words)
Severe chest pain (constant tightness or crushing sensation)
Feeling confused or unsure of where you are
Losing consciousness
None of the above
Do you have any of the following symptoms?:
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Fever (hot to touch, temp of 37.8C or higher)
Chills
Cough that's new/worsening (continuous, more than usual)
Barking cough,making a whistling noise when breathing
Shortness of breath (out of breath, unable to breath deeply)
Sore throat
Difficulty swallowing
Runny or stuffy nose (not related toseasonal allergies or other known causesor conditions)
Loss of taste or smell
Pink eye (conjunctivitis)
Headache that is unusual or long-lasting
Nausea/vomiting/diarrhea/abdominal pain
Muscle aches
Unexplained fatigue/malaise
Falling down often
None of the above
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
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Yes
No
Have you been in contact with anyone who has since tested positive for COVID-19?
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Yes
No
Have you been in a group of more than 10 recently?
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Yes
No
Have you traveled outside of Ontario in the last 14 days?
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Yes
No
Are you in close contact with a person who is sick with new respiratory symptoms or who recently traveled outside of Ontario?
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Yes
No
Notes / Comments
Disclaimer: By signing my name below. I am electronically signing this application.
Screener Signature
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