HAZLOC Consultants & Training, COVID-19 Health Questions

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Please complete the following daily health questions for entry into HAZLOC Consultants & Training Center. If you answer "Yes" to any of the questions below, please do not enter / visit the Training Center and immediately contact us and your health professional for further advise / assistance.

Email *

Today's Date *

YYYY

Do you feel or have any of the following:

Do you feel very Hot or Cold?

Yes

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Are you sweating or shivering?

Yes

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When you touch your forehead, does it feel Hot?

Yes

Clear selection

Do you have a cough that recently started?

Yes

Clear selection

Do you have a sore throat or pain when swallowing?

Yes

Clear selection

Do you have breathlessness / short of breath or difficulty breathing that you noticed recently?

Yes

Clear selection

Have you noticed any recent changes in your ability to taste or smell things?

Yes

Clear selection

Do you have any body aches or pains including headaches?

Yes

Clear selection

Have you had any close contact with anyone with confirmed or probable case of COVID-19 in the last 14 days?

Yes

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Please let us know if you have a pre-exisiting medical condition we should be aware of (e.g. obesity, diabetes, hypertension, cardiovascular disease)? *

Finally, please confirm that the information you provided is accurate to the best of your knowledge and that you give the National Department of Health permission to contact you if required *

Confirm

Required

You will be sent an email of your responses. If you responded "Yes" to any question, please do not enter / visit our center. If you responded "No" to all the questions, please print / present the email at reception to secure entry.

A copy of your responses will be emailed to the address you provided.

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