Important COVID-19 Announcement
COVID-19 Screening
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COVID-19 Screening Questionnaire
For the health and safety of our therapists, staff and all others within the clinic, please answer all questions below honestly.
Name and Date
Name
*
First
Last
Date of Appointment
*
Date Format: MM slash DD slash YYYY
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.