COVID 19 - Screening
Required Field
Personal Info
First Name
Last Name
Contact Info
Email
Conditions
COVID-19 Screening Questions
Have you had any changes to your medical history since the initial intake?
Yes
No
Are you willing to wear face mask in the clinic?
Yes
No
Do you agree to wear face mask during treatment?
Yes
No
Have you tested positive for COVID-19?
Yes
No
Do you have a fever over 38 degrees?
Yes
No
Are you experiencing headaches?
Yes
No
Do you have difficulty swallowing?
Yes
No
Do you have a sore throat?
Yes
No
Have you had a new cough develop recently?
Yes
No
Are you experiencing difficulty breathing?
Yes
No
Do you have a persistent pain in your chest?
Yes
No
Do you have decrease or sudden loss of taste and smell?
Yes
No
Have you had a new onset of muscle aches and pain since the emergence of the virus?
Yes
No
Do you have unexplained fatigue/malaise/muscle aches (myalgia)?
Yes
No
Are you experiencing fatigue?
Yes
No
Are you experiencing chills?
Yes
No
Have your recently developed nasal or sinus congestion?
Yes
No
Do you have nausea?
Yes
No
Do you have diarrhea?
Yes
No
Have you been vomiting?
Yes
No
Have you been experiencing abdominal pain?
Yes
No
Have you had a sudden onset body aches?
Yes
No
Have you been in contact with anyone with COVID-19?
Yes
No
Are you in high or moderate risk groups?
Yes
No
Any recent domestic air travel?
Yes
No
Any recent international air travel?
Yes
No
Any recent travel to area with high infection rates?
Yes
No
Any recent travel outside your province within the past 14 days?
Yes
No
Did you travel outside of Canada in the past 14 days?
Yes
No
To the best of your knowledge, within the last 14 days has any member of your household or support bubble tested positive for COVID-19 or experienced any COVID-19 symptoms?
Yes
No
Are you required to be self-isolating for any reason?
Yes
No
What is your temperature?
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