COVID-19 Screening Name(Required) First Last Phone(Required)Email(Required) Date(Required) YYYY slash MM slash DD Time(Required) Hours : Minutes AM PM AM/PM 1. 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 or chills Difficulty breathing or shortness of breath Cough Sore throat, trouble swallowing Runny nose/stuffy nose or nasal congestion Decrease or loss of smell or taste Nausea, vomiting, diarrhea, abdominal pain Not feeling well, extreme tiredness, sore muscles 2. Have you travelled outside of Canada in the past 14 days or have been in a close contact with someone who has travelled outside of Canada in the past 14 days?(Required) Yes No 3. Have you had close contact with a confirmed or probable case of COVID-19?(Required) Yes No 4. Are you aware and following the recommendations and restrictions regarding gathering size, hand and respiratory hygiene, and the use of PPE?(Required) Yes No 5. Do you acknowledge that you are expected to properly wear your PPE at all times except when eating?(Required) Yes No 6. Do you acknowledge that at any time your PPE is removed you must maintain a distance of 2 meters or 6 feet from others?(Required) Yes No CAPTCHAConsent(Required) I agree to future contact with VERA Home Care
