Patient COVID-19 Intake Screening Tool
PLEASE NOTE: In addition to symptoms, if you have been at an exposure site, notified by public health or the COVID Alert App that you have been exposed, your appointment will be moved to telehealth or rescheduled.
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Date of pre-appointment screen *
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Patient initials *
Physiotherapist Initials *
Do you have a fever/chills? *
Do you have a cough (new or worsening)? *
Do you have a sore throat? *
Do you have a runny nose/nasal congestion? *
Do you have a headache? *
Do you have any shortness of breath? *
Do you live with a person who has COVID-19 or who has recovered from COVID-19 less than 14 days ago or less than 14 days since they received a positive test OR with someone who has been exposed and told to self-isolate? *
In the past 14 days, have you traveled outside of Atlantic Canada? *
If yes, are you fully vaccinated (minimum 2 weeks post second dose)?
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In the past 14 days, have you had close contact (within 2m) with someone who traveled outside of Atlantic Canada? *
If yes, was this person fully vaccinated (minimum 2 weeks post second dose)? and/or not required to Isolate?
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In the past 14 days, have you had close contact (within 2m) with someone who has been diagnosed with COVID-19 or someone with symptoms? *
Have you been notified by any public health authorities that you may have been exposed to COVID-19 and are required to self-isolate? *
Have you been to any of the potential exposure locations (https://novascotia.ca/coronavirus/alerts-notices/#possible-exposures) on the identified dates and times? *
Have you been notified by the COVID Alert App that you may have been exposed to COVID-19 in the last 14 days? *
Are you awaiting test results because you have were experiencing symptoms or are apart of a contact tracing investigation? *
Within the last 2 weeks, have you been in a group more than 25 people indoors or 50 people outdoors where physical distancing guidelines were not followed? (exception of sports, performing arts, and events) *
In the last 28 days, have you been diagnosed or treated for COVID-19? *
Are you a front line worker with occupational exposure to someone with COVID-19 in the last 14 days and did not use PPE? *
Explanation for any of the above (allergies, etc if symptoms have been present for over a month).
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