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Health Questionnaire (July 2021)

The document is a COVID-19 health questionnaire completed by Alejandro Maldonado on August 13, 2021. It includes questions about vaccination status, symptoms, recent travel, and contact with COVID-19 cases, with Alejandro indicating he is vaccinated and not experiencing any symptoms. He acknowledges the health risks and agrees to report any future symptoms.

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AlexMaldonado
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22 views1 page

Health Questionnaire (July 2021)

The document is a COVID-19 health questionnaire completed by Alejandro Maldonado on August 13, 2021. It includes questions about vaccination status, symptoms, recent travel, and contact with COVID-19 cases, with Alejandro indicating he is vaccinated and not experiencing any symptoms. He acknowledges the health risks and agrees to report any future symptoms.

Uploaded by

AlexMaldonado
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COVID-19

HEALTH QUESTIONNAIRE
DATE: NAME Alejandro Maldonado
08/13/2021
HOME CONTACT
76 west 62 avenue Vancouver +52 1 9993350971
ADDRESS: PHONE #:

Have you been vaccinated?


☐ No ☐
✔ Yes ( )
Prefer not to answer (please note this will have no bearing on your
ability to work for Pristine Labour, we ask simply for our records ☐ ☐ Yes ( 2)
and should you be on a site where there is a positive case
identified).

1. Are you experiencing any of the following:


✔ No
☐ ☐ Yes
• Fever
• New onset or worsening of cough or other symptoms
• Sneezing/Running Nose
• Sore throat
• Difficulty breathing
• Severe Fatigue
• Vomiting

2 Have you travelled to any countries outside Canada (including the ☐ No ✔ Yes
☐
United States) within the last 14 days?

3 Did you provide care or have close contact with a person with
✔ No
☐ ☐ Yes
COVID-19 (probable or confirmed) while they were ill (cough, fever,
sneezing, or sore throat) within the last 14 days?

4 Did you have close contact with a person who travelled outside of ✔ No
☐ ☐ Yes
Canada in the last 14 days who has become ill (cough, fever,
sneezing, or sore throat)?

5 Have you or anybody in your home had contact with someone who ✔ No
☐ ☐ Yes
is being tested for COVID-19 or who has been diagnosed with
COVID-19.

I am aware and understand the health risks of potentially spreading COVID-19 to others. I willingly agree to report any
future symptoms and medical diagnosis including recommending work after sickness. I understand that I may be asked to
stay at home following current or future symptoms and orDigitally
thesigned
development
by Alejandro
of COVID-19; flu/cold and flu-like symptoms.
Alejandro
DN: cn=Alejandro, o, ou,
Alejandro Maldonado
_______________________ ______________________
[email protected]
om, c=MX
08/13/2021
_____________________
Date: 2021.08.13 19:46:17 -07'00'

Print Name Signature Date

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