Covid Form

Chatham Mazda | Covid Form

Symptom Screening Form

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?
 Yes No
Difficulty breathing or shortness of breath?
 Yes No
Cough?
 Yes No
Sore throat or trouble swallowing
 Yes No
Runny nose/stuffy nose or nasal congestion?
 Yes No
Decrease or loss of smell or taste?
 Yes No
Nausea, vomiting, diarrhea, abdominal pain?
 Yes No
Not feeling well, extreme tiredness, sore muscles?
 Yes No
Have you travelled outside of Canada in the past 14 days?
 Yes No
Have you had close contact with a confirmed or probable case of COVID-19?
 Yes No
If you have answered yes to any of the above questions you are not to enter the work place. Please self-isolate and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.