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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?
    YesNo

    New onset of cough or worsening chronic cough?
    YesNo

    Shortness of Breath?
    YesNo

    Decrease or loss of sense of taste or smell?
    YesNo

    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)?
    YesNo

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

    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:
    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.


    Signature