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Patient COVID-19 Screening Tool
If you would like to attend Kamloops Physiotherapy, completion of this form is required each time prior to entering our clinic.
Please complete this form on the same day of your appointment, BEFORE you arrive.
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* Indicates required question
First and Last Name
*
Your answer
Are you experiencing a new onset of any of the following symptoms? IF YOU HAVE ANY OF THE SYMPTOMS LISTED BELOW, PLEASE DO NOT ATTEND THE CLINIC. Call and postpone your appointment and isolate at home as per BC CDC guidelines.
*
Fever or chills
Cough (either a new cough or worsening of a chronic cough)
Shortness of breath
Sore throat
Loss or change of sense of smell or taste
Headache (a new or different or worsening headache)
Extreme fatigue or tiredness
Runny nose (new or worsening and unrelated to typical allergies)
Sneezing (new or worsening and unrelated to typical allergies)
Diarrhea
Loss of appetite
Nausea or vomiting
Body or muscle aches
No I am not experiencing any of these symptoms or other symptoms of a potentially communicable disease
Required
I have been informed of the safety precautions that Kamloops Physiotherapy and Sports Injury Centre has in place. I agree that I will perform proper hand hygiene, properly wear a well fitting medical style mask with good filtration, and follow all other guidelines as directed.
Yes I agree with the above statements and I choose to attend Kamloops Physiotherapy and consent to proceeding with my appointment.
No
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