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 or anyone in your household travelled outside of Manitoba in the past 14 days?***

Yes
No

e) 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

**Exemptions from self-isolation (quarantine) orders include some essential workers and those that are fully immunized, if they have no symptoms.

***Exemptions are in place for asymptomatic household members if they are an essential worker required to wear medical grade PPE while at work, such as health care workers and first responders.

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

e) Vomiting or diarrhea for more than 24 hours*

Yes
No

f) Shortness of breath/breathing difficulties*

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: