Mandatory COVID-19 Screening

Name *

First Name

Last Name

1. Do you have a fever? *

Yes

No

2. Do you have any of the following signs or symptoms? *

New onset of cough

Worsening chronic cough

Sore throat

Shortness of breath

Difficulty breathing

New loss or decrease in sense of taste or smell

Runny nose (not allergy related)

Sneezing (not allergy related)

Hoarse voice

Nasal congestion

Chills

Headache (new or unusual)

Unxplained fatigue or malaise

Difficulty swallowing

Nausea/vomiting, diarrhea, abdominal pain

NONE OF THE ABOVE SYMPTOMS

3. Have you or any one in your household traveled outside Canada in the past 14 days? *

Yes

No

4. Have you had close contact with anyone with respiratory illness or a positive or probable/suspected case of COVID-19 in the past 14 days? *

Yes

No

5. If no SKIP this question. If yes did you wear the required and/or recommended PPE according to the type of duties you were performing (eg. goggles, gloves, mask and gown or N95 with aerosol generating medical procedures) when you had close contact with a suspected or confirmed case of COVID-19?

Yes

No

Please check the boxes to acknowledge and agree:*

I hereby confirm that the information above is true to the best of my knowledge and would like to proceed with my service on this basis. I will contact SHYpractice if the information or circumstances change.

I consent to wearing a mask while in the studio

I am aware of the risks of acquiring COVID-19 and I take full responsibility for my decision to receive my service