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