Patient questionnaire

(Confidential - to be attached to the file)

Infection prevention and control measures
Update 07.10.2021
Source: Therapeutic care in private practice - Measures (inspq.qc.ca) Questionnaire of COVID-19 symptoms | INSPQ

A "YES" to only one of the following symptoms REQUIRES rescheduling an appointment YES NO
Do you have the feeling of being feverish, having chills like flu, fever (oral temperature 38.1 ° C [100.6 ° F)?
Have you had a recent cough or a recently worsened chronic cough?
Do you have a sudden loss of smell without nasal congestion, with or without loss of taste?
Are you having difficulty breathing or are you short of breath?
Do you have a sore throat?
Do you have a runny nose or stuffy nose (of unknown cause)?
Have you been instructed to place yourself in administrative segregation (eg: returning from an international trip, contact
with a confirmed case of COVID-19)?
A "YES" to at least 2 of the following symptoms REQUIRES rescheduling an appointment
Stomach ache
Diarrhea
Nausea or vomiting
Severe or unusual fatigue
Significant loss of appetite
Generalized muscle pain or unusual stiffness
Unusual headache

If you answered NO to all of these questions,

the acupuncturist can proceed with the treatment.

Otherwise
1. Postpone your appointment;
2. Return to your home;
3. Contact 1 877 644-4545.

I declare that the above information is correct and I undertake to apply the infection prevention and control measures indicated
above. I agree to inform the acupuncturist of any change in my condition related to
COVID-19. - VERBAL VALIDATION AT EACH VISIT

Patient name: _________________________________________________________________________________________

Signature: ___________________________________________________ Date: ____________________________________