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) been in contact with anyone showing signs of COVID19?
*
Yes
No
b) worked in a lab involving COVID 19?
*
Yes
No
c) been on a flight?
*
Yes
No
d) travelled outside of Manitoba?
*
Yes
No
2. Do you have ANY of the following “A symptoms”?
a) Fever
*
Yes
No
b) Cough
*
Yes
No
c) Sore throat
*
Yes
No
d) Difficulty breathing
*
Yes
No
Do you have 2 or more of the following “B symptoms”?
a) Runny nose
*
Yes
No
b) Muscle aches
*
Yes
No
c) Fatigue
*
Yes
No
d) Loss of smell or taste
*
Yes
No
e) Headache
*
Yes
No
f) Hoarse voice
*
Yes
No
g) Nausea, vomiting or diarrhea for more than 24 hours
*
Yes
No
If you answered yes to ANY of the above, please explain:
Message
