Covid-19 Questionnaire Covid-19 Questionnaire Name * Al Chudnovsky Alfredo Pimentel Ashley Black Atley Stock Andre Smith Austin McClenaghan Bari McFarland Brad Thompson Bob Smilsky Brett Sontag Charlie Cowling Dan Cirimele Dave Lauterbach David Coulter Don Brooks Doug Verpaelst Gabe Jenkinson James Murphy JF Lemieux John Gobel Jordan Scott Josh Reisman Julie Fleger Kaiden Raney Kelly Douglas Kyle Beaudette Laura Meikle Les Coburn Lori Reynolds Mark Turney Matt Little Morgan Fitzgerald Nigel Hollidge Rem Fielding Richard Gobel Robert Link Ryan Chatwin Sally Brooks Scott Clayworth Shar Harbridge Tanner Sleep Teena Mason Tyler Gobel Wendy Crothers Do you have any of the following symptoms or signs? Severe difficulty breathing (struggling for each breath, can only speak in single words) Severe chest pain (constant tightness or crushing sensation) Feeling confused or unsure of where you are Losing consciousness Fever (feeling hot to the touch, a temperature of 37.8 degrees Celcuis or higher) Chills Cough that's new or worsening (continuous, more than usual) Barking cough, making a whistling noise when breathing (croup) Shortness of breath (out of breath, unable to breathe deeply) Sore throat Difficulty swallowing Runny nose (not related to seasonal allergies or other known causes or conditions) Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions) Lost sense of taste or smell Pink eye (conjunctivitis) Headache that's unusual or long lasting Digestive issues (nausea/vomiting, diarrhea, stomach pain) Muscle Aches Extreme tiredness that is unusual (fatigue, lack of energy) Falling down often In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? Close phyiscal contact means: being less than 2 meters away in the same room, workspace, or area for over 15 minutes living in the same home In the last 14 days, have you been in close physical contact with a person who either: is currently sick with a new cough, fever or difficulty breathing? returned from outside of Canada in the last 2 weeks? Have you travelled outside of Canada in the last 14 days? Answer - If the answer is yes to any of the above questions, indicate yes below. Yes No Please explain below and immediately contact Bari McFarland at (705) 826-2295 Submit If you are human, leave this field blank.