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?

    New onset of cough or worsening chronic cough?

    Shortness of Breath?

    Decrease or loss of sense of taste or smell?

    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)?

    4- Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?

    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.

    1.     I have answered all the above questions honestly and truthfully
    2.     By signing below, I consent and accept the inherent risks of in-person physiotherapy treatment in light of the COVID-19 Pandemic and any potential exposure that occurs as a result.