Self-Screening & Student Service Agreement

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Please complete this self-screening questionnaire upon each visit.

If you answer 'yes' to any of the questions below, please notify an Eikonic staff member and we will be happy to help you reschedule an appointment for a future date.

Thank you for your ongoing help and co-operation.

First and last name *

Phone Number *

In the last 14 days, have you travelled outside of Canada and were told to self-isolate? *

In the last 14 days, did someone you live with return from outside of Canada and is isolating while waiting for COVID-19 test results? *

In the last 5-10 days, have you had any of the following symptoms that are not related to known causes or conditions? *

Fever and/or chills (Temperature of 37.8 C)

Cough or barking cough (Continuous, more than usual, whistling noise)

Shortness of breath (Out of breath, unable to breathe deeply)

Decrease or loss of taste or smell (Unrelated to allergies or disorders)

Muscle aches/joint pains (Unusual, long-lasting, non-injury)

Extreme tiredness (Unusual fatigue, no energy)

Sore throat (Painful, difficulty swallowing)

Runny or stuffy/congested nose (Unrelated to allergies, cold weather)

Headache (New, unusual, long-lasting)

Nausea, vomiting, and/or diarrhea (Unrelated to IBS, anxiety, menstrual cramps)

None of the above

Required

In the last 5-10 days, have you tested positive for COVID-19, or been in close contact to someone who has been tested positive for COVID-19? *

Do you live with someone who is currently isolating because of a positive COVID-19 test, isolating because of COVID-19 symptoms or is waiting for a COVID-19 test result?

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Have you been identified as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate? *

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