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 any of the following apply to you? *

I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose series)
I have tested positive for COVID-19 in the last 90 days (and since been cleared)
Neither applies to me

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.

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 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).

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/joint pain *

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

Fatigue *

Unusual tiredness, 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 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”

Pink eye *

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

Headache *

Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.”

In the last 14 days:

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

This can be because of an outbreak or contact tracing, or after testing positive on a rapid antigen test.

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Have you been identified as a “close contact” of someone who currently has COVID-19? *

Have you received a COVID Alert exposure notification on your cell phone? *

If you already went for a test and got a negative result, select “No.”

Have you travelled outside of Canada? *

If you are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, select “No”.

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

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.