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 – Have you, or anyone in your house, travelled internationally or out of province within the past 2 weeks?
2- Have you been in contact with anyone in the past 2 weeks that has tested positive for COVID-19?
3- Do you currently have ANY of the following symptoms? Fever of 38C / 100.4F or higher?
New Onset or worsening of chronic Cough?
Shortness of Breath?
Flu Like Symptoms (Fatigue, Joint Pain, Muscle Ache)?
4- Does anyone living in your household have ANY of the above symptoms?
5- Have you or anyone in your house tested positive for COVID-19?
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.
Your Name (required)
Your Email (required)