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=alexmaldonado94@hotmail.c
om, c=MX
08/13/2021
_____________________
Date: 2021.08.13 19:46:17 -07'00'

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