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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 NO.
    2 – Have you travelled outside of Canada in the past 14 days? YesNo
    3- Have you come in contact with a confirmed case of COVID-19 in the past 14 days without wearing appropriate PPE? YesNo
    4- 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
    5- 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
    6- 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: I have answered all the above questions honestly and truthfully
    Signature

    The content provided on this website is for informational purposes only. It is not a substitute for professional diagnosis, treatment or medical advice.

    11685 Yonge St A106, Richmond Hill, ON L4E 0K7
    • Call Us (905) 237-7174
    • manager@premiercarephysio.com
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    Daily 8:30am – 8:00pm
    Fri 8:30am – 4:00pm
    Sat 9:00am – 2:00pm
    Closed Sundays

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