Gym 41 COVID Screening

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Mandatory to enter building

What is your name? *

Are you currently experiencing any of these issues? Call 911 if you are: *

Severe difficulty breathing (struggling for each breath, can only speak in single words)

Severe chest pain (constant tightness or crushing sensation)

Feeling confused or unsure of where you are

Losing consciousness

None of the above

Required

How old are you? *

18 to 29 years old

30 to 39 years old

40 to 49 years old

50 to 59 years old

60 to 69 years old

70 to 79 years old

80 years old or older

What are the first 3 characters of your postal code? *

Are you currently experiencing any of these symptoms? (Choose any/all that are new, worsening, and not related to other known causes or conditions.) *

Fever (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

Chills

Cough that's new or worsening (Continuous, more than usual, not related to other known causes or conditions (for example, COPD))

Barking cough, making a whistling noise when breathing (Croup, not related to other known causes or conditions)

Shortness of breath (Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma))

Sore throat (Not related to other known causes or conditions (for example, seasonal allergies, acid reflux))

Difficulty swallowing (Painful swallowing, not related to other known causes or conditions)

Runny nose (Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather))

Stuffy or congested nose (Not related to other known causes or conditions (for example, seasonal allergies))

Decrease or loss of taste or smell (Not related to other known causes or conditions (for example, allergies, neurological disorders))

Pink eye (Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes))

Headache that’s unusual or long lasting (Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines))

Digestive issues like nausea/vomiting, diarrhea, stomach pain (Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps))

Muscle aches that are unusual or long lasting (Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia))

Extreme tiredness that is unusual (Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction))

Falling down often (For older people)

Sluggishness or lack of appetite (For young children and infants)

None of the above

Required

Are you in any of these at-risk groups? *

Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder)

Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD)

Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

None of the above

Required

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? (This includes getting a COVID Alert exposure notification.) *

Yes

In the last 14 days, have you been in close physical contact (less than 2m distance away, living in same room, same classroom) with someone who either: *

Is currently sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19?

Returned from outside of Canada in the last 2 weeks?

None of the above

Required

Have you travelled outside of Canada in the last 14 days? (This does not include essential workers who cross the Canada-US border regularly.) *

Yes

Do you need a COVID-19 test for a specific reason? *

Visiting, working, or living in a nursing or long-term care home

Before getting surgery

Working or living in a homeless shelter or other congregate setting

For travel outside Canada

Being an international student or farm worker

None of the above

Other:

Required

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