COVID-19 Screening Questionnaire

(To be completed by any individual (employee, volunteer, client, etc.) entering the practice. Screening should occur before or when a worker enters the practice at the beginning of their day or shift, and before a client or other visitor is admitted inside the practice.)

Staff/Visitor Name:*
First Last
Visitor Contact Number:*
1. Are you exhibiting any of the following symptoms? (please check off all symptoms that you have been experiencing)*
- 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
- I am not experiencing any of the above symptoms.
2. Have you travelled outside of Canada in the past 14 days*
- Yes
- No
3. Have you had close contact with a confirmed or probable case of COVID-19?*
- Yes
- No
Signature*
Date*
Date Format: MM slash DD slash YYYY
Results of Screening Questions:
-If the individual answers NO to all questions, they have passed and can enter the workplace.
-If the individual answers YES to any question, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor workplaces). They should go home to self-isolate and contact their health care provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.

Beattie Pet Hospital –
Burlington

1231 Appleby Lane
Burlington, ON L7L 5H9
Phone: 289-919-1231

Beattie Pet Hospital –
Stoney Creek

131-135 Upper Centennial Parkway
Stoney Creek, ON L8J OB2
Phone: 289-639-5600

Beattie Pet Hospital –
Ancaster

34 Stone Church Road Suite 100
Ancaster, ON L9K 1S5
Phone: 289-639-5540

Beattie Pet Hospital –
Brantford

70 Paris Road
Brantford, ON N3R 1H9
Phone: 519-756-1770