COVID-19 Patient Screening Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form prior to your appointment. This ensures we maintain a safe and positive experience for everyone at Peach Physiotherapy & Wellness Centre.

This form was taken from the Ontario Ministry of Health COVID-19 Screening Tool for Long-Term Care Homes and Retirement Homes.

1. Patient's first and last name: *

2. Do you have any of the following new or worsening symptoms or signs? *

New or worsening cough

Shortness of breath

Sore throat

Runny nose, sneezing or nasal congestion (in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)

Hoarse voice

Difficulty swallowing

New smell or tasting disorder(s)

Nausea/vomiting, diarrhea, abdominal pain

Unexplained fatigue/malaise

Chills

Headache

NONE OF THE ABOVE

Required

3. Have you traveled outside of Canada or had close contact with anyone that has traveled outside of Canada in the past 14 days? *

Yes

4. Do you have a fever? (37.8*C or greater) *

Yes

5. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19? *

Yes

6. If the patient has answered "No" to all of the above questions, please check that they agree to the following (all boxes must be checked):

Wear a mask during their treatment (either a clean mask from home or a procedure mask purchased at Peach PT)

Sanitize their hands upon entry into Peach PT

Arrive to their appointment on time to ensure physical distancing

Attend the appointment alone or with a single guardian

7. Does the patient agree to the following statement? "I agree that the responses I provided are true to the best of my knowledge. I am aware of the risks of entering the clinic and I have been informed of the safety precautions that Peach Physiotherapy has in place. I consent to proceeding with in-person-care and having this information collected by the clinic for my safety and the safety of others".

I agree

I disagree

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Peach Physiotherapy & Wellness Centre. Report Abuse

Forms