COVID-19 Self Assessment Tool

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We ask that for your safety and the safety of our clients, staff and clinical space, that you please fill out this form to the best of your ability, no more than 24 hours prior to attending your appointment.

Please be honest - by answering "Yes" to any of the questions, does not automatically prevent you from attending your scheduled appointment.

We thank you for your time and attention to this self-assessment tool.

Last Name *

First Name *

If you have answered YES to any of the questions, or are experiencing any symptoms, we ask that you please contact the office at 306-933-3372 for further discussion.

Do you have any of the following - click all that apply *

Temperature greater than 38°C or 100.4°F

Cough

Shortness of breath

Sore throat

Loss of taste or smell

Loss of appetite

Nausea or vomitting

Chills

Fatigue

Dizziness

Headache not related to the reason for your physiotherapy appointment

Muscle or joint pain not related to the reason for your physiotherapy appointment

None of the above

Required

Were you exposed to someone who is under investigation for COVID-19 or has been confirmed as having COVID-19 within the last 10 days? *

Yes

If you have answered YES to any of the questions, or are experiencing any symptoms, we ask that you please contact the office at 306-933-3372 for further discussion.

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