COVID-19 SCREENING form

Please fill in the following form to the best of your ability. Filling in this form will help make our appointment more efficient.

First Name

Last Name

Date of Birth

Specific Screening Questionnaire

Please answer to the best of your ability. If unsure please ask your therapist for clarification.

Do you have a fever?

Yes

Not sure

Do you have any of the following new or worsening symptoms or signs

New or worsening cough

Shortness of breath

Sore throat

Runny Nose/Sneezing

Nasal congestion

Hoarse voice

Difficulty swallowing

New loss or decrease in sense of taste or smell

Chills

Headache

Unexplained fatigue or malaise

Nausea/vomiting, diarrhea, abdominal pain

NONE OF THE ABOVE

Have you traveled outside of Canada or had close contact with anyone that has traveled outside of Canada in the past 14 days?

Yes

Not sure

Have you had close contact with anyone with a respiratory illness or a confirmed or probable case of COVID-19?

Yes - go to next Question

No - survey complete

Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures when you had close contact with a suspected or confirmed case of COVID-19?

Yes