Covid-19 Screening
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Do you exhibit any of the below conditions?
Yes
No
Fever (temp of 100 degrees or more)
Cough
Shortness of breath or difficulty breathing
Body aches
Chills
Runny or stuffy nose
Sore throat
Diarrhea
In the last 14 days:
Yes
No
1 - Has anyone in your household been diagnosed with Covid-19?
2 - Have you been told to quarantine yourself by any public health authority in the last 2 weeks?
3 - Have you been in close contact (less than 6 ft for a prolonged period) with someone who has tested positive for Covid-19?
4 - Have you traveled anywhere outside of Canada in the last month?
5 - Have you traveled anywhere outside of Ontario in the last 2 weeks?
*
If I begin to show any symtoms of COVID-19 within the next two weeks, I will contact my stylist!
*
I will follow all salon rules to keep myself, my stylist and others safe.
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