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 sanitize your hands upon entering the workplace.  If physical distancing will be a challenge, you must wear a mask.

 

Question Title

* 1. Please enter your contact information

Question Title

* 2. Do you have ANY of the following NEW or WORSENING symptoms or signs? Symptoms should not be chronic or related to other known cause of conditions (for individuals who are 18 years of age or older).

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

- Cough or barking cough (croup): Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (i.e. asthma, post-infectious reactive airways, COPD)

- Shortness of breath: Out of breath, unable to breathe deeply, not related to other known causes or conditions (i.e. asthma)

- Decrease or loss of smell or taste: Not related to other known causes or conditions (i.e. allergies, neurological disorders)

- Sore throat: Not related to other known causes or conditions (i.e. seasonal allergies, acid reflux)

Difficulty Swallowing: Painful swallowing, not related to other know causes or conditions

Pink Eye: Conjunctivitis, not related to other known causes or conditions (i.e. reoccurring styles)

- Runny or stuffy/congested nose: Not related to other known causes or conditions (i.e. seasonal allergies, being outside in cold weather)

Headache that's unusual or long lasting: Not related to other known causes or conditions (i.e. tension-type headaches, chronic migraines)

Digestive issues like nausea/vomiting, diarrhea, stomach pain:  Not related to other known causes or conditions (i.e. IBS, menstrual cramps)

Muscle aches that are unusual or long lasting: Not related to other known causes or conditions (i.e. a sudden injury, fibromyalgia)

Extreme tiredness that is unusual: Fatigue, lack of energy, not related to other known causes or conditions (i.e. depression, insomnia, thyroid dysfunction)

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

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