Statement

The information collected in this questionnaire will be used and disclosed information solely for the purposes of determining fitness for working out during the COVID-19 pandemic in accordance with Travis Wade Fitness obligations to provide a safe work and clinical environment for Travis Wade Fitness trainers and clients.
Ensure at all times you are following protocols for hand hygiene and also remember to clean your keys, phone, computers and other personal items.
We understand that people may have seasonal or environmental allergies. Related symptoms to these scenarios would not preclude them from working out. The following questions are meant to capture new symptoms, or a worsening of long-standing symptoms.


COVID-19 Screening Form

Your Name:

Do you have any of these symptoms?
Fever of 38.0C or higher YesNo
New onset of (or exacerbation of a chronic) cough YesNo
Shortness of Breath YesNo
Difficulty breathing YesNo
Sore Throat YesNo
Runny/Stuffy Nose YesNo

Assessment Questions
Have you returned to Canada from outside the country (including USA) in the last 14
days?		 YesNo
Do you live with or have had close contact* (within 2 meters/6 feet) with a person with an
influenza-like illness (ILI) who had travelled outside of Canada in the 14 days before their
illness started, while: 1) not wearing recommended PPE at work and/or 2) not practicing
social distancing as appropriate to the setting?		 YesNo
Do you live with or have had close contact* (within 2 meters/6 feet) with a person with an
influenza-like illness (ILI) who had close contact with a lab-confirmed COVID-19 case,
while: 1) not wearing recommended PPE and/or 2) not practicing social distancing as
appropriate to the setting?		 YesNo
Have you had close contact* (within 2 meters/6 feet) with a confirmed or probable case of
COVID-19, while: 1) not wearing recommended PPE and/or 2) not practicing social
distancing?		 YesNo

Directions/Definition
Notify your trainer by calling them (do not email or text) if you answer yes to any of the above. These
forms will be monitored remotely and deleted after 21 days.
*PPE is not expected to apply in the home setting.
If you answer "YES" to any of the above, you will not be permitted to attend training at this time.
NOTIFY a trainer by a phone call immediately.
If you answer "NO" to all of the above, you can proceed to start your training.



*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 with the
person without consistent and appropriate use of personal protective equipment OR who lived with or
otherwise had close prolonged contact (within 2 meters) 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