COVID Screening

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COVID Screening Survey

Please fill out our COVID Screening Survey the day of your class before visiting us... namaste!

* Indicates required field

Name *

First

Last

Email *

Are you currently experiencing any of these symptoms? *

Fever and/or chills Cough or barking cough Shortness of breath Muscle aches/joint pain Extreme tiredness Decrease or loss of taste or smell Runny or stuffy/congested nose Sore throat Headache Nausea, vomiting and/or diarrhea None of the above

In the last 5 days has someone you live with: *

Been sick with symptoms associated with COVID-19? and/or Tested positive for COVID-19 (on a rapid antigen test or PCR test? None of the above

In the last 5 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

Yes No

In the last 5 days, have you received a COVID Alert exposure notification on your cell phone? *

Yes No

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

In the last 5 days, have you been identified as a “close contact” of someone who currently has COVID-19? Confirmed by a PCR or rapid antigen test. *

Yes No

If public health has advised you that you do not need to self-isolate, select “No.”

In the last 14 days, have you travelled outside of Canada? *

Yes No

If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.”

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

Yes No

Have you been in close physical contact with someone experiencing symptoms of COVID in the last 5 days? *

Yes No

Close physical contact means any of the following while NOT wearing PPE: - being less than 2 meters away in the same room, workspace or area. - living in the same home

Submit

CONTACT US

20 Freel Lane
Stouffville, ON
L4A 8B9
905.642.4600