Intake | Donna Sarna

Name and Date

Name*

First Last

Date of Appointment*

1. In the last 14 days, have you...

a) Have you been in close contact (within two meters/six feet for more than 15 minutes) with anyone who has tested Positive for COVID19 and is not deemed "recovered" by Public Health?*

Yes
No

b) Have you been exposed to COVID-19 in a workplace setting without wearing the required PPE (personal protective equipment)?*

Yes
No

c) Have you received a notification from the COVID Alert app that you may have been exposed to COVID-19?*

Yes
No

d) Have you been in contact with anyone who has worked in a lab involving COVID 19 biological specimens?*

Yes
No

e) Have you or anyone in your household travelled outside of Canada, or within Canada, east of Terrance Bay, Ontario in the past 14 days?*

Yes
No

f) If someone in your household has travelled outside Manitoba within the last 14 days, have you been in close contact with them since their return from travel?*

Yes
No

** If you have answered "yes" to any of the following questions please DO NOT ENTER**

2. Do you have any of the following “A symptoms?”

a) Fever (greater than 38 degrees Celsius), feverish or chills*

Yes
No

b) "New" onset of cough or frequency in the amount of coughing*

Yes
No

c) "New" onset of sore throat/hoarse voice*

Yes
No

d) Loss of smell or taste*

Yes
No

d) Vomiting or diarrhea for more than 24 hours*

Yes
No

3. Do you have 2 or more of the following “B Symptoms?”

a) Sore muscles not related to over exertion or exercise*

Yes
No

b) Runny nose*

Yes
No

c) Fatigue*

Yes
No

d) Unusual Headache*

Yes
No

e) Conjunctivitis (pinkeye)*

Yes
No

f) Skin rash of unknown cause*

Yes
No

g) Nausea or loss of appetite*

Yes
No

If you answered yes to ANY of the above, please explain:

Message

Liability Checkbox*

Donna Sarna Physiotherapy has extensive protocols in place to make our clinic as safe as possible. However, by attending my appointment I voluntarily accept and assume the associated risks including possibly contracting the COVID-19 virus. I am aware of the nature and effect of this disclaimer of liability and I fully understand these conditions before attending my appointment.

Physiotherapy & Rehabilitation

COVID-19 Screening Questionnaire

Name and Date

1. In the last 14 days, have you...

2. Do you have any of the following “A symptoms?”

3. Do you have 2 or more of the following “B Symptoms?”

If you answered yes to ANY of the above, please explain: