COVID-19 Screening Questionnaire

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The Physio Approach
(647) 299-7728 - thephysioapproach@gmail.com

Email *

First and last name *

Date *

YYYY

1. Do you have a fever? *

Yes

2. Do you have any of the following signs or symptoms? (Check all that apply) *

New onset of cough

Worsening chronic cough

Difficulty breathing

Shortness of breath

Sore throat

Difficulty swallowing

New loss/decrease in sense of taste or smell

Chills

Unusual or long lasting headache

Unexplained fatigue / malaise / muscle ache

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis)

Runny Nose/Nasal congestion

None of the above

Required

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

Yes

4. Are you currently awaiting COVID-19 test results? *

Yes

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

Yes (if yes, go to question 6)

No (if no, skip question 6)

6. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures) when you had close contact with a suspected or confirmed case of COVID-19?

Yes

Clear selection

If you answered "yes" to questions 1-5, or checked off signs or symptoms, you may need to reschedule your appointment and book a Telehealth appointment. If you answered "yes" to question 5 but "yes" to question 6, you may proceed with your appointment.

Legal Waiver: **Please review** I hereby acknowledge that I have agreed to meet with the Health Care Provider (HCP) at The Physio Approach (the “Facility”) for the purpose of receiving therapeutic services provided (the “Services”). I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending at the Facility. I also acknowledge and accept that while receiving services, the HCP may need to be closer than the recommended social distancing guidelines in order to assess and/or treat me. I acknowledge and confirm that I am willing to accept this risk as a condition of attending at the Facility to receive services from the HCP. In consideration of the HCP agreeing to see me in person at the Facility, I agree to release the HCP and the Facility, (the “Releasees”) from any and all causes of action, claims, demands, requests, damages or any recourse whatsoever in respect of any personal injuries or other damages which may occur or arise as a result of exposure to COVID-19 during my visit to the Facility and/or through the provision of services to me by the HCP. I do hereby acknowledge and agree that notwithstanding the generality of the foregoing, I declare that I will not commence litigation or otherwise seek to recover damages or other compensation against the Releasees based on any action, claim, demand, request, loss or any recourse whatsoever arising from any potential or actual exposure to COVID-19 while attending at the Facility and/or through the provision of services to me by the HCP. I further acknowledge that the Releasees can rely on this Release of Liability, Waiver of all Possible Claims and Assumption of Risk as a complete defense to any and all claims, damages, causes of action, or recourse or liability that may arise at any time. *

I agree

I disagree (and acknowledge that I can't attend services at the centre)

Consent: By clicking below I agree that: The responses I provided are true to the best of my knowledge; I am aware of the safety precautions that The Physio Approach has in place; I am aware of the risks of in-person care and consent to proceeding; I consent to having this information collected by the clinic for my safety and the safety of others *

I agree to all of the above

Submit

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