COVID 19 SCREENING

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

I do NOT have any of the following symptoms (or combination of): Fever (feeling hot to the touch, temperature of 37.8( Celsius or higher); Cough that's new or worsening (continuous, more than usual), barking cough; A squeaky or whistling noise when breathing (croup); Difficulty breathing, shortness of breath (out of breath, unable to breathe deeply).

I am NOT experiencing any of the following otherwise unexplained symptoms: muscle ache, fatigue, headache, sore throat, hoarse voice (more rough or harsh than normal), difficulty swallowing, stuffy, congested or runny nose, chills, lost sense of taste/smell, digestive issues(nausea/vomiting, diarrhea,stomach pain), fatigue(lack of energy, extreme tiredness), falling down more than usual.

I have NOT had close contact with someone who has, or is suspected of having, COVID-19

I have NOT travelled outside of Canada in the past 14 days

I have NOT had close contact with someone who has travelled internationally and has a fever and/or cough and/or difficulty breathing

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Whitby Studio - 100 Dundas St W Whitby, corner of Brock and Dundas

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100 Dundas St. W, Whitby, Ontario L1N 2L9 Floor 3

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