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Weston Road COVID-19 Health Screening Questionnaire
Email Address:
Full name (of dancer, staff or person entering The Dance Zone:
Phone Number:
Date:
Participant's Temperature Today (indicate C or F):
Have you experienced any of the following symptoms in the last 24 hours ?:
Fever (temperature of 37.8 C / 100.4 F or greater)
New or worsening cough
Runny nose or nasal congestion (unrelated to seasonal allergies, post nasal drip, etc)
Shortness of breath/Difficulty breathing
Sore throat or difficulty swallowing
New smell or taste disorders
Nausea/Vomiting, Diarrhea/Abdominal pain
Chills
Headaches
Unexplained fatigue/malaise/muscle aches
Pink eye (conjunctivitis)
Red/purple discolouration to hands, fingers, feet and/or toes and skin may peel
Croup
Worsening of chronic conditions
None of the above
Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days?:
Yes
No
Have you or anyone in your household tested positive for COVID-19 in the last 14 days?:
Yes
No
Have you or anyone in your household recently been tested for COVID-19 and are awaiting results?:
Yes
No
Have you or anyone in your household had close contact with anyone with a confirmed or probable diagnosis of COVID-19 or who is being tested for COVID-19 within the past 14 days?:
Yes
No
:
A copy of your responses will be emailed to the address you provided.
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