COVID-19 Self Assessment Screening Questionnaire

1. Have you travelled outside of Canada in the past 14 days?

2. Do you have a confirmed case of COVID-19 OR have you had close contact with a confirmed case of COVID-19 without wearing appropriate personal protective equipment (PPE)?

3. Do you have any of the following symptoms:

    • Fever
    • New onset of cough
    • Worsening chronic cough
    • Shortness of breath
    • Difficulty breathing
    • Sore throat
    • Difficulty swallowing
    • Decrease or loss of sense of taste or smell
    • Chills
    • Headache that is unusual or long lasting
    • Unexplained fatigue/malaise/muscles aches
    • Nausea/vomiting, diarrhea, abdominal pain
    • Pink eye (conjuntivitis)
    • Runny nose/nasal congestion without other known cause

4. If you are over the age of 70, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

If you responded YES to any of the above questions, please consider speaking with your MD/local public health authorities, and you must delay your appointment.

Before booking an appointment and again immediately prior to the appointment, all clients will be screened for COVID-19.