Covid-19 Screening Form - MapleCare Physiotherapy

Full Name*

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Email*

Background Question:

Have you been fully vaccinated (received your second dose more than 14 days ago)?

* A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e., Johnson and Johnson).

Yes
No

Screening Questions:

Do you currently 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 •Headaches •Unexplained fatigue/malaise/muscle aches (myalgias) •Nausea/vomiting, diarrhea, abdominal pain •Pink eye (conjunctivitis) •Runny nose/nasal congestion without other known cause

Yes
No

Have you tested positive for COVID-19 in the past 10 days or been told you should be isolating?*

Yes
No

You only need to answer these questions if you are not fully immunized.

Have you traveled outside of Canada in the past 14 days?*

Yes
No

Have you had close contact with a confirmed case of COVID-19 without wearing appropriate personal protective equipment (PPE)?*

Yes
No

If your response to all screening questions is “No” your COVID screening is negative, please continue with your appointment.

If you screen positive, please call the clinic to cancel your “in-person" appointment and discuss alternate treatment options. Please call Public Health Ottawa at 613-580-6744 for further advice.

Declaration:

I have answered all the above questions honestly and truthfully.
By signing below, I consent and accept the inherent risks of in-person physiotherapy treatment in light of the COVID-19 Pandemic and any potential exposure that occurs as a result.

Please write Patient/Visitor Full Name below which serves as electronic signature:*

Name

This field is for validation purposes and should be left unchanged.