Vaughan
416-801-8889
Woodbridge
888-220-1479
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Vaughan
Woodbridge
COVID-19 Screening Questionnaire
Are you currently experiencing any of these symptoms?
1) Are you currently experiencing any of these symptoms: Fever and or chills 37.8 degrees or higher, cough, shortness of breath, sore throat, difficulty swallowing, pink eye Conjunctivitis, runny or stuffy/congested nose, unusual headache, nausea or vomiting, diarrhea, stomach pains, muscle aches, extreme tiredness, or falling down?
Yes
None of the Above
2) Have you travelled outside of Canada in the last 14 days?
Yes
No
3) In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?
Yes
No
4) Has a doctor, health care provider, or public health unit told you or anyone in your household that they should currently be isolating (staying at home)?
Yes
No
5) In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?
Yes
No
STOP!
Please do not proceed to the office.
Contact your therapist ASAP to schedule your appointment virtually.
VAUGHAN OFFICE 416-801-8889
WOODBRIDGE OFFICE 888-220-1479
Please print your name below with email and phone number. Then sign inside the box to confirm your answers.
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