Covid-19 – Aesthetically Yours By Mel

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Covid-19 Screening Questionnaire

screening

Please fill out the below questionnaire

In order to protect our clients, our home and ensure we are all following proper Covid-19 procedures and protocols, we ask you kindly fill out the below questionnaire prior to your arrival for your appointment. Upon arriving a temperature check will also be completed. A Facemask/covering is required at all times in accordance with Niagara Regional Public Health guidelines.

Name *

First

Last

Email *

Phone Number *

In the past 24 hours, have you experienced any of the following symptoms associated with COVID-19? ▪ Fever/chills ▪ New cough or a cough that is getting worse ▪ Difficulty breathing ▪ Shortness of breath (even when sitting or walking regularly) ▪ Sore throat (not due to allergies) ▪ A runny or congested nose (not due to allergies) ▪ Unusual level of fatigue ▪ Unusual headache ▪ Nausea/vomiting, diarrhea, or loss of appetite ▪ Feeling unwell for an unknown reason *

In the past 24 hours, has anyone in your household (other than yourself) experienced any *symptoms, not due to a previously known chronic condition diagnosed by a health care professional and has not received a negative COVID-19 test result with respect to those symptoms? *

In the past 14 days, have you been in close contact with someone who has *symptoms of COVID-19, and 1) has traveled to a more heavily affected area of Canada 14 days prior to symptoms appearing or 2) had close contact with a confirmed case of COVID-19 or 3) has lived in or worked in a place with a confirmed outbreak of COVID-19 or 4) has been tested and results are unknown, and has not been told they can come out of isolation? *

In the past 14 days, were you or someone you live with 1) advised to consult with a health care professional about COVID-19, but chose not to do so, or 2) advised to get tested for COVID-19, but chose not to do so, or 3) tested for COVID-19 due to *symptoms, but have not yet received the results? *

Have you returned from travel outside Canada in the past 14 days? (This does not include essential workers who cross the border regularly for the purposes of performing an essential job or function as per the Order issued under the Quarantine Act) *