Gateway Painting Daily Covid Screening Form 1. Do you have any of the following unexplained symptoms: Fever or Chills YesNo Difficulty breathing or shortness of breath YesNo Cough YesNo Sore throat, trouble swallowing YesNo Runny nose/stuffy nose or nasal congestion YesNo Decrease or loss of smell or taste YesNo Nausea, vomiting, diarrhea, abdominal pain YesNo Not feeling well, extreme tiredness, sore muscles YesNo 2. Have you travelled outside of Canada in the past 14 days? YesNo 3. Have you had close contact with a confirmed or probable case of COVID-19? YesNo Thanks for completing the screening form! If any symptoms appear that could change your answer to any of the questions over the course of the day, please inform us immediately. Stop! You are a potential risk for COVID-19. Do not enter the workplace and return home to self-isolate immediately. Contact your healthcare provider or Telehealth Ontario at +1 866-797-0000 to determine if you require a COVID-19 test.