Intake | Donna Sarna

Name and Date

Name*

First Last

Date of Appointment*

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

a) returned from travel outside of Manitoba, with the exception of travel to Western Canada, the Territories (Nunavut, NWT, Yukon) and Northwestern Ontario (west of Terrence Bay)?*

Yes
No

b) been in contact with anyone who tested Positive for COVID19 and is not deemed "recovered" by Public Health?*

Yes
No

c) been in contact with anyone who is showing signs of COVID19?*

Yes
No

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

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

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”?

Do you have 2 or more of the following “B symptoms”?

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