The Province of Ontario is requiring businesses to perform a mandatory Covid-19 screening of all staff prior to any work shift regardless of vaccination status. Please read each question carefully and select the answer that applies (Yes or No).

The information collected from this questionnaire remains confidential to Natural Sole Wellness Centre only. We do not share this information with Public Health establishments.

Name *

Date (mm-dd-yyyy) *

1. Are you currently experiencing any of these symptoms? *

• The symptoms listed here are the symptoms most commonly associated with COVID-19. If you have these symptoms, you should isolate and seek testing. Please note that rapid antigen testing is not to be used for those with symptoms of COVID-19 or for contacts of known COVID-19 cases. Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from their health care provider if needed. Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills *

• Yes
• No

Temperature of 38 degrees Celsius or higher and/or chills.

Cough or barking cough (croup) *

• Yes
• No

Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions you already have)

Shortness of breath *

• Yes
• No

Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease or loss of taste or smell *

• Yes
• No

Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Tiredness *

• Yes
• No

Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.

Muscle aches *

• Yes
• No

Unexplained, unusual, or long-lasting (not related to sudden injury, fibromyalgia, or other known causes or conditions) If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”

2. Have you been in close contact with a confirmed or probable case of COVID-19 and are required to self-isolate/quarantine as per Ottawa Public Health? *

• Yes
• No

3. In the last 14 days, have you travelled outside of Canada and been advised to quarantine as per the federal quarantine requirements? *

• Yes
• No

4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

• Yes
• No

This can be because of an outbreak or contact tracing.

5. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? *

• Yes
• No

If you have since tested negative on a lab-based PCR test, select “No.”

6. Are you currently awaiting results for a COVID-19 test? *

• Yes
• No

Submit