COVID

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Email

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Willing to sanitise hands when entering and leaving clinic

Willing to wear face mask in the clinic

Agree to wear face mask during treatment

Have you taken precautions to limit exposure

Have you tested positive for COVID-19?

Have you been tested for COVID?

Fever Over 38 degrees

Headaches

New Onset of Cough

Worsening Chronic Cough

Sore Throat

Difficulty Swallowing

Shortness of Breath

Difficulty Breathing

Persistent Pain in Chest

Decrease or sudden loss of taste and smell

Have you had a new onset of muscle aches and pain since the emergence of the virus?

Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)

Fatigue

Chills

Pink eye (conjunctivitis)

Nasal or sinus congestion

Runny nose/nasal congestion without other known cause

Nausea

Vomiting

Diarrhea

Abdominal Pain

Sudden onset body aches

New rash or other skin changes

Can you exercise to get your heart rate up without any problem?

Can you exercise to get your respiratory rate up without any problem?

Contact with someone with COVID

Are you in high or moderate risk groups?

Have you been shielding?

Recent domestic air travel

Recent international air travel

Recent travel to area with high infection rates

Recent travel outside your province within the past 14 days

Did you travel outside of Canada in the past 14 days?

In the past 2 weeks, have you or someone with whom you interact traveled outside the Atlantic Bubble?

Been in group where social distancing not observed