COVID-19 Client Screening

Welcome to Youngs Insurance! Please complete our COVID-19 Client Screening below.

Client Full Name: *

Contact Number: *

What Youngs Insurance office are you visiting? *

Select from below Fort Erie London Mississauga Niagara Falls Port Colborne St. Catharines Waterdown Welland

What Youngs Insurance employee are you meeting with? *

In the past 24 hours, have you experienced any symptoms, not due to previously known chronic conditions diagnosed by a health care professional?

• Fever and/or chills
• New cough or a cough that is getting worse
• Shortness of breath
• Decrease or loss of smell or taste
• Fatigue, lethargy, malaise (general feeling of being unwell, lack of energy, extreme tiredness)
• Nausea, vomiting, and/or diarrhea
• Muscle aches or pain not related to getting a COVID-19 vaccine in the last 48 hours
• Sore throat (painful or difficulty swallowing)
• Headache not related to getting COVID-19 vaccine in the last 48 hours
• Runny nose/nasal congestion
• Abdominal pain
• Conjunctivitis (pink eye)

*

YES

NO

In the past 24 hours, has anyone in your household (other than yourself) experienced any symptoms (listed above), not due to a previously known chronic condition diagnosed by a health care professional AND has not received a negative COVID-19 test result with respect to those symptoms? If you are fully vaccinated and you have not been advised to self-isolate by Public Health select 'No'. *

YES

NO

In the last 10 days, have you been identified as a 'high-risk contact' with someone who currently has COVID-19? If you are fully vaccinated and you have not been advised to self-isolate by Public Health select 'No'. *

YES

NO

In the past 10 days, have you been in close contact with someone who has symptoms of COVID-19, AND has travelled to a more heavily affected area of Canada 10 days prior to symptoms appearing OR has been tested and lab results are inconclusive, and Public Health has not released them from isolation? If you are fully vaccinated and you have not been advised to self-isolate by Public Health select 'No'. *

YES

NO

In the past 10 days, were you advised to consult with a health care professional about COVID-19, but chose not to do so, OR advised to get tested for COVID-19, but chose not to do, OR tested for COVID-19 due to symptoms, but have not received the result? This question does not pertain to those who were tested as part of workplace surveillance. *

YES

NO

In the past 10 days, was someone you live with advised to consult with a Health Care Professional about COVID-19, but chose not to do so, OR advised to get tested for COVID-19 but chose not to do so, OR tested for COVID-19 due to symptoms but have not yet received the result? This question does not pertain to those who live with someone who was tested as part of workplace surveillance. If you are fully vaccinated and you have not been advised to self-isolate by Public Health select 'No'. *

YES

NO

In the past 10 days, have you travelled outside of Canada? If you are exempt from quarantine requirements because you are an essential worker or you are fully vaccinated, select 'No'. *

YES

NO

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IF YOU SELECTED "YES" TO ANY OF THE ABOVE QUESTIONS, PLEASE RE-SCHEDULE YOUR APPOINTMENT AND FOLLOW THESE STEPS:

Next steps

1. You should isolate (stay home) and not leave except to get tested or for a medical emergency
2. Talk with a doctor/health care provider or call Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test