COVID SCREENING (PASSIVE SCREENING)

1) Have you travelled or have had close contact with anyone who has travelled in the past 14 days?*
Yes _____

No _____

2) Do you have a fever?

Yes _____

No _____

3) Do you have any of the following signs or symptoms?

• New onset of cough ___
• Worsening chronic cough___
• Shortness of breath___
• Difficulty breathing___
• Decrease of loss of sense of taste or smell___
• Chills___
• Headaches___
• Unexplained fatigue/malaise/muscle aches___
• Nausea/vomiting, diarrhea, abdominal pain___
• Pink eye (conjunctivitis) ___
• Runny nose or nasal congestion without other known cause___

4) If you are 70 years of age or older, are you experiencing any of the following symptoms?

• Delirium___

• Unexplained or increase number of falls___

• Acute functional decline___

• Worsening of chronic conditions

5) Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case
of COVID-19?*
 Yes____

No_____

6) Did you wear the required and/or recommended PPE according to the type of duties you were performing
(e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures when you had
close contact with a suspected or confirmed case of COVID-19?
Yes____

No____

If you have answered “yes” to questions 1, 2, or have checked off signs or symptoms, you may need to
reschedule your appointment.

If you have answered “yes” to question 5 but “yes” to question 5, you may proceed with your appointment.

* COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to Health
Canada, senior citizens and those with underlying medical conditions are especially vulnerable. By visiting Reform
Pelvic Health Physio, you voluntarily assume all risks related to exposure to COVID-19

Signature:

danusha gnaneswarn
Full Name: __________________

25/01/2021
Date: _______________________