Covid-19 Screening Questionnaire

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Please fill out our Covid-19 Screening Questionnaire before your appointment.

Email *

Please enter today's date: *

YYYY

Please enter your first and last name: *

Are you currently vaccinated? *

Yes

If you answered yes to the above question, how many doses have you received?

I am not vaccinated

Clear selection

Are you currently experiencing any of the issues below? *

Severe difficulty breathing (struggling for each breath, can only speak in single words)

Severe chest pain (constant tightness or crushing sensation)

Feeling confused or unsure of where you are

Losing consciousness

None of the above

Required

Have you experienced any of the following symptoms in the past 10 days? (Please do not show up to your appointment if you answered yes to any of the questions below). *

Fever and/or chills (temperature of 37.8 degrees celsius/100 degrees fahrenheit or higher)

Cough or barking cough (continuous, more than usual, making a whistling noise when breathing – not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have).

Shortness of breath (out of breath, unable to breathe deeply, not related to asthma or other known causes or conditions you already have).

Decrease or loss of taste or smell (not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have).

Muscle aches/joint pain - unusual, long-lasting, and not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have

Extreme tiredness – unusual fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours), depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have

Sore throat, painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

Headache – new, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48-hours) tension-type, headaches, chronic migraines, or other known causes or conditions you already have

Nausea, vomiting and/or diarrhea (not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have)

None of the above

Required

In the last 10 days, has someone you live with been sick with symptoms associated with COVID-19, and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)? *

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

Yes

In the last 10 days, have you received a COVID alert exposure notification on your cellphone? *

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19, confirmed PCR or rapid antigen test? *

Yes

In the last 14 days, have you travelled outside of Canada? *

Yes

If you answered NO to all the above, then it is safe for you to attend your appointment. For your protection you are required to always wear a NON-CLOTH FACE MASK in the office. Also, please use hand sanitizer on the way in and out of the office. Temperature will be taken upon entry for all staff and clients. *

I understand

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