COVID-19 SCREENING QUESTIONNAIRE
Due to the COVID-19 pandemic, we are required to ask following questions which were provided by the Ministry of Ontario Health. This form should be completed before entering the premise. If response to ANY of the screening questions is YES, customer must not enter the premise. The customer should contact their primary care provider or Telehealth Ontario at 1-866-797-000. One person from the same group or table can fill the form.
Have you (or anyone in your group) travelled outside of Canada in the last 14 days?
In the last 14 dyas, has a public health unit identified you (or anyone in your group) as a close contact of someone who currently has COVID-19?
Has a doctor, health care provider, or public health unit told you (or anyone in your group) that you should currently be isolating (staying at home)?
In the last 14 days, have (or anyone in your group) you received a COVID Alert exposure notification on your cell phone?
Are you (or anyone in your group) currently experiencing any of these symptoms? (Fever/Chills/Cough or barking cough/Shortness of breath/Sore throat/Difficulty swallowing/Runny or stuffy nose/Decrease or loss of taste or smell/Pink eye/Unusual or long lasting headache/Nausea, Vomitting, diarrhea, stomach pain/Unusual or long lasting muscle aches/Unusual Extreme tiredness/Falling down often)