Covid 19 Health Screening Form ~ La Vecchia Lakeshore

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To help us prevent the spread of COVID-19, we ask you to read this carefully and answer the questions below. Please act accordingly following the screening questions.

Please complete the form prior to entering the restaurant
* Required Fields

Email *

Examples of symptoms include the new onset of:

• A new or worsening cough
• Shortness of breath or difficulty
breathing
• Temperature equal to or
over 38°C
• Feeling feverish
• Chills
• Fatigue or weakness
• Muscle or body aches
• Headache
• New loss of smell or taste
• Gastrointestinal symptoms
(abdominal pain, diarrhea,
vomiting)
• Feeling very unwell

If ‘yes’ is answered to any
of questions 1-4, do not
enter the site.

Full Name *

Please enter you first and last name

Have you been in close contact with someone who is sick or has confirmed case of COVID-19 in the past 14 days? *

Yes

I don't know

In the past two weeks were you outside of the country. *

Yes

Do you have any of the following symptoms *

Difficulty breathing

Sore Throat

Nausea, vomiting or diarrhea

Loss of taste or smell

Runny nose

Cough

None of the Above

Other:

Required

If more than one person, are you and your guest from the same household? *

Yes

Single diner

Send me a copy of my responses.

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