Covid Questionnaire – Women Who Wine Society

Visitor Screening Form

This form must be completed before Thursday July 23^rd to confirm your attendance to the event on July 24^th, 2020 at Harpur Farm.

Visitor Name (required)

Vistor Email (required)

Address

Phone Number

1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?
yesno

2. Do you have any of these symptoms: Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
yesno

3. Have you experienced a recent loss of smell or taste?
yesno

4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
yesno

5. Have you returned from travel outside of Canada in the last 14 days?
yesno

6. Have you returned from travel within Canada from a location majorly affected with COVID-19?
yesno

7. Are you over the age of 70?
yesno

8. Do you have any of the following: Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
yesno