Covid-19 Screening - Family Chiropractic Centre

First Name *

Last Name *

1 - Email Address

2 - Phone Number *

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions

3 - Fever or chills *

NoYesNo

4 - Difficulty breathing or shortness of breath *

NoYesNo

5 - New onset of cough or worsening chronic cough *

NoYesNo

6 - Sore throat or trouble swallowing *

NoYesNo

7 - Runny nose/stuffy nose or nasal congestion *

NoYesNo

8 - Decrease or loss of taste or smell *

NoYesNo

9 - Nausea, vomiting, diarrhea, abdominal pain *

NoYesNo

Travel & Exposure risk

10 - Have you travelled outside of Canada in the past 14 days? *

NoYesNo

11 - Have you had close contact with a confirmed or probable case of COVID-19, or tested positive for COVID-19 within the past 14 days? *

NoYesNo

If you answered NO to all questions, you are cleared to enter the workplace. If you answered YES to any of the questions, you are not granted permission to enter the workplace. You should immediately go home to self-isolate, and contact your local health care provider or Telehealth Ontario (1-866-797-0000) to find out if you need a Covid-19 test.

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Signature :

Covid-19 Screening - Family Chiropractic Centre

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The information has been received.

Did you enjoy the Colib experience?

Click the link below to learn how Colib can help you and your company with digital forms.

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions

Travel & Exposure risk

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