FHC Covid-19 Symptoms Checklist | Farhi Holdings Corporation

484 Richmond St, London, ON N6A 3E6

Name*
First Last
Work Email*
Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions
Fever or Chills*
- Yes
- No
Difficulty breathing or shortness of breath*
- Yes
- No
Cough*
- Yes
- No
Sore throat, trouble swallowing*
- Yes
- No
Runny nose/stuffy nose or nasal congestion*
- Yes
- No
Decrease or loss of smell or taste?*
- Yes
- No
Nausea, vomiting, diarrhea, abdominal pain?*
- Yes
- No
Not feeling well, extreme tiredness, sore muscles?*
- Yes
- No
Have you had close contact with a confirmed or probable case of COVID-19?*
- Yes
- No
Have you travelled outside of Canada in the past 14 days?*
- Yes
- No
Have you been tested for COVID-19 in the past 14 days?*
- Yes, the results were negative
- Yes, the results were positive
- Yes, I am awaiting the results
- No, I have not been tested
If you have been tested, what date did you take your test on?
Date Format: DD slash MM slash YYYY