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All patients are required to complete the screening checklist below prior to each appointment.The form must be submitted on the day of your scheduled appointment.
Full Name
Today's Date
Do you have any of the following symptoms?
- Fever - New onset of cough - Worsening chronic cough - Shortness of breath - Difficulty breathing - Sore throat - Difficulty swallowing - Decrease or loss of sense of taste or smell - Chills - Headaches - Unexplained fatigue/malaise/muscle aches (myalgias) - Nausea/vomiting, diarrhea, abdominal pain - Pink eye (conjunctivitis) - Runny nose/nasal congestion without other known cause
YesNo
Have you tested positive for COVID-19 OR had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
Have you had close contact with a person who is sick with new respiratory symptoms or with a confirmed case of COVID-19? Close contact is when you spent longer than 15 minutes with the person while not consistently physically distancing (less than 6 feet apart) with or without wearing a mask. This includes people that you may have worked or socialized with.
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
YesNoNot Applicable
Through submitting this form, I hereby confirm that the information I have provided above is true, and that I will comply with the terms and conditions outlined by the policy and procedures of King City Physiotherapy.
I agree
