COVID-19 Health Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Severe difficulty breathing (i.e., struggling to breathe or speaking in single words), Severe chest pain, Having a very hard time waking up, Feeling confused, Losing consciousness
  • Shortness of breath at rest, Inability to lie down because of difficulty of breathing, Chronic health conditions that you are having difficulty managing because of difficulty breathing
  • Fever, Cough, Sneezing, Sore Throat, Difficulty Breathing
  • I hereby declare that the information provided is true and correct.

If you have checked YES to any questions, you are not permitted on the premises and you should consider seeking medical attention.

If you have checked NO but you notice a change in your health within the next 14 days, we ask you notify the public health authority immediately.

If you are in a high-risk group for COVID-19 (i.e., over the age of 65, pre-existing respiratory condition) please determine with your supervisor if working on this site is appropriate for you given current COVID transmission risks.

We share a responsibility for keeping each other safe. Thank you for completing this questionnaire. If you have any questions, please contact a Low Tide Properties Building Operator or call 604-737-7232.