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Home
Home
Services
Physiotherapy
Personal Injury Rehab Clinic
Pelvic Floor Physiotherapy
Sports Injuries
Pre/Post Surgical Rehabilitation
Custom Foot Orthotics
Neuropathy
Massage Therapy
Orthopaedic Manual Therapy
Chiropractic care
Chiropody foot care
Medical Acupuncture
Active Exercise Program
Home Care Physiotherapy
Fall Risk Assessment and Treatment
Intramuscular Stimulation (IMS)
Mobility Aids Assessment and Prescription
Bracing
About
About
Team
Testimonials
Insurance Companies
FAQ
Patients
GLA:D Program
Blog
Contact
Forms
Consent Form
Appointment Requests
COVID Form
Safety
Screening Questionnaire - Part 2
For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic
Please Carefully read and answer ALL following questions:
1 – Did you receive your final (or second) vaccination dose more than 14 days ago?
You Answered YES.
2- Do you currently have ANY of the following symptoms? Fever (of 38C / 100.4F or higher) and/or chills?
Yes
No
New onset of cough or worsening chronic cough?
Yes
No
Shortness of Breath?
Yes
No
Decrease or loss of sense of taste or smell?
Yes
No
3- Adults over 18 years of age (Any unexplained fatigue, joint pain or muscle ache) or Child under 18 years of age (Any nausea, vomiting or diarrhea)?
Yes
No
4- Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?
Yes
No
If you answer “YES” to any of above question, we ask that you immediately contact the clinic at 905-237-7174 to discuss appropriate next steps and in-person appointments alternatives.
Declaration:
I have answered all the above questions honestly and truthfully
Signature
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