COVID-19 Screening Questionnaire

If you are are a Bespoke Audio Visual employee, independent contractor, or guest, please fill out this questionnaire prior to arriving at our offices or job sites. Learn more about how we are navigating our business and supporting our clients during COVID-19.

Name *

First

Last

Date *

Please fill out this form the day-of, prior to your arrival.

Phone *

Email *

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.

Fever and/or chills *

Temperature of 37.8. degrees Celsius/100 degrees Fahrenheit or higher.

Cough or barking cough *

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

Shortness of breath *

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

Sore throat, trouble swallowing *

Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have. Painful swallowing (not related to other known causes or conditions you already have).

Runny or stuffy/congested nose *

Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.

Decrease or loss of smell or taste *

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

Digestive issues like nausea/vomiting, diarrhea, stomach pain *

Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have.

Muscle aches, extreme tiredness *

Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have). Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have).

Pink eye *

Not related to reoccurring styes or other known causes or conditions.

Headache *

Unusual, not related to causes or conditions you already have.

In the last 14 days:

Have you travelled outside of Canada? *

Have you had close contact with a confirmed or probable case of COVID-19? *

If you answered YES to any of the above questions please go home & self-isolate immediately. You should contact your health care provider or call Telehealth Ontario at 1 (866) 797-0000 to speak to a registered nurse.

I declare that the above statements are true.

Signature *

Comment

COVID-19 Screening Questionnaire

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.

In the last 14 days:

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.