2022 Covid Screening Form

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Please submit this Covid screening before attending each session to help us keep your family and our clinic safe. These questions follow the current Ontario school screening requirements.

If you answer 'Yes' to any of the below, please do not enter the premises but contact the office at 289 678 0581 to switch to a virtual session or to reschedule your appointment.

Email *

Option 1

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Date *

YYYY

Name *

In the last 5 days, have you experienced any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. Select “None of the above” if symptoms have been improving for 24 hours and you tested negative for COVID-19 on a single PCR test or two rapid antigen tests taken 24 to 48 hours apart. Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours and seek assessment from their health care provider if needed. *

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup) - 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)

Sore throat - Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, 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

Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, 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

Muscle aches/joint pain - Unusual, long-lasting (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)

None of The Above

Do any of the following international travel scenarios apply to you? In the last 14 days: you travelled outside of Canada and were told to quarantine, OR, you travelled outside of Canada and were told to not attend school/child care, OR, someone you live with returned from outside Canada and is isolating while waiting for COVID-19 test results? NOTE: If a child/student is not fully vaccinated but is exempt from federal quarantine because they travelled with a fully vaccinated companion, they must not go to school/child care for 14 days. Select “Yes” if this applies. *

Yes

In the last 5 days, have you tested positive for COVID-19? This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test, or home-based self-testing kit. *

Yes

Do any of the following apply? You live with someone who is currently isolating because of a positive COVID-19 test OR You live with someone who is currently isolating because of COVID-19 symptoms OR You live with someone who is waiting for COVID-19 test results? Select “No” if the person has not tested positive for COVID-19 and only has one of these symptoms: sore throat or difficulty swallowing, runny or stuffy/congested nose, headache, extreme tiredness, muscle aches or joint pain, nausea, vomiting and/or diarrhea. *

Yes

Did you answer "Yes" to any of the above?

If you answered 'Yes' to any of the questions please do not enter the premises but contact the office at 289 678 0581 to switch to a virtual session or to reschedule your appointment.,

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