Winter M&S - COVID-19 Daily Pre-screening Questionnaire

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You will be required to submit this questionnaire *the morning of* your Movers & Shakers class, prior to entering the building.

Full Name *

Body Temperature - must be taken the morning of *

Are any of the above named participants experiencing any of the following symptoms? *

Fever and/or chills

Runny or stuffy/congested nose

Cough

Shortness of breath or difficulty breathing

Sore throat or difficulty swallowing

Loss of appetite, decreased sense of taste or smell

Fatigue, extreme tiredness or feeling sluggish

Headache

Nausea, vomiting, and/or diarrhea

None of the above

Required

If you indicated Yes to any symptoms above, please indicate which participant is experiencing them.

Have you traveled outside of Leeds and Grenville area within the last 14 days? *

Yes

Has a doctor, health care provider, or public health unit told you or the above named participants should currently be isolating (staying at home)? *

Yes

Is someone that the above named participant(s) lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes

In the last 14 days, have you or the above named participants received a COVID Alert exposure notification on their cell phone? *

Yes

Have you been in close physical contact with someone who is ill, or been in close physical contact with someone with a confirmed case of COVID-19? *

Yes

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