FORMS | Beauty Beyond Skin Deep

Name *

First

Last

Phone

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have any concern for a potential COVID 19 infection? *

Yes
No

Have you followed all social distancing rules/guidelines implemented by the Ontario Government? *

Yes
No

Have you had any close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? *

Yes
No

Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19? *

Yes
No

A close contact is defined as a person who: Provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact without consistent and appropriate use of personal protective equipment; or Lived with or otherwise had close prolonged contact (within 2 metres) with the person while they were infectious; or Had direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on) while not wearing recommended personal protective equipment Are you 70 years of age or older? If so, are you experiencing any of the following symptoms: Delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes
No

Do you have any of the following symptoms:

New onset of cough? *

Yes
No

Worsening chronic cough? *

Yes
No

Mild to moderate shortness of breath? *

Yes
No

Sore throat? *

Yes
No

Difficulty swallowing? *

Yes
No

Decrease or loss of sense of taste or smell? *

Yes
No

Headaches? *

Yes
No

Unexplained fatique/malaise/muscle aches? *

Yes
No

Nausea, vomiting, diarrhea, abdominal pain? *

Yes
No

Pink eye (conjunctivitis)? *

Yes
No

Runny nose/nasal congestion without other known cause? *

Yes
No

Having a hard time waking up? *

Yes
No

Feeling confused? *

Yes
No

Loss off consciousness? *

Yes
No

Inability to lie down because of difficulty in breathing? *

Yes
No

Severe chest pain? *

Yes
No

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words) *

Yes
No