COVID-19 Health Check Questionnaire

Annex Business Media requires all employees and visitors entering our workplace to complete a COVID-19 Health Check questionnaire prior to arrival.  Thank you for keeping yourself and those around you healthy and safe!

If you answer “YES” to any of the questions below, while we would love to see your smiling face in person, unfortunately we are unable to allow you to enter the workplace or interact face-to-face with our employees.  Please stay home and self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to determine if you need a COVID-19 test. Don’t forget to call your manager to update them on your current status.

If you answer “NO” to all of the questions below, please remember to wear a mask at all times when in our building (except when you are in an office space, alone and with the door closed or are in the lunch room sitting down and eating) and to sanitize your hands upon entering the workplace.  

If any answers below change during the day, please inform your manager and HR and go home to self-isolate immediately and contact your health care provider or Telehealth Ontario to get advice or an assessment, including if you need a COVID-19 test.

Question Title

* 1. Please enter your contact information

Question Title

* 2. Are you currently experiencing  ONE or MORE of the symptoms below that are NEW or WORSENING? Symptoms should not be chronic or related to other known causes of conditions (for individuals who are 18 years of age or older).

- Fever and/or chills: Temp of 37.8 degrees Celcius/100 degrees Fahrenheit or higher.

- Cough or barking cough (croup): Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have.

- Shortness of breath: Not related to asthma or other known causes or conditions you already have.

- Sore throat: Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.

- Difficulty swallowing: Painful swallowing, not related to 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.

- Pink eye: Conjunctivitis (not related to reoccurring styes or 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.

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

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

- Extreme tiredness: Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have). If you have received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select "NO".

- Falling down often: More of a concern for people of an advanced age.

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