KBB Covid Screening Questionnaire

Client Name* This field is required.

First Name

Last Name

Date* This field is required.

Date

Are you currently experiencing any of these symptoms?* This field is required.The symptoms listed here are the most commonly associated with COVID-19. Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from their health care provider if needed.

Fever and/or chills. Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

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

Shortness of breath. Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease or loss of taste or smell. Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Muscle aches/joint pain. Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness. Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Sore throat. Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, 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. New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Nausea, vomiting and/or diarrhea. Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have

None of the above

In the last 10 days, has someone you live with:* This field is required.been sick with symptoms associated with COVID-19? and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)?

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?* This field is required.

Yes

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?* This field is required.

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)?* This field is required.If public health has advised you that you do not need to self-isolate, select “No.”

Yes

In the last 14 days, have you travelled outside of Canada?* This field is required.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.”

Yes

Based on your answers, you may proceed to your appointment at Kelly's Barber & Beauty.

If you feel sick or not well at any time before your appointment, please stay home until symptoms improve for at least 24 hours or 48 hours if you have gastrointestinal symptoms (nausea, vomiting, diarrhea).

To protect your community and the health care system and your service providers, please wear a face covering or mask when required, keep a physical distance from others, and wash your hands as much as possible.

Please note that we currently have a 50% capacity limit and you may have to wait in your car until your appointment if you arrive early. It is advised that only ONE parent attend an appointment with their children to help keep capacity within limits.

I agree not to visit the salon for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

Based on your answers, please do NOT proceed to your visit at Kelly's Barber & Beauty. We are required to reschedule your appointment.

Please feel free to reschedule your appointment after symptoms have improved for at least 24 hours or 48 hours if you have gastrointestinal symptoms (nausea, vomiting, diarrhea). You can do this by calling the salon, using our Kelly's Barber & Beauty app, or going to our website www.kellysbarbernbeauty.ca.

Thank you for doing your part to keep our community and service providers safe.

Parent/Guardian Name (if applicable)

First Name

Last Name

Client/Parent/Guardian Signature* This field is required.

Clear

KBB Covid Screening Questionnaire