COVID-19 Screening Please fill out this form prior to your appointment. Find LocationFind us on a Google map. Patient BookingCall or use contact form. ServicesLearn how we can help. COVID-19 Screening Form Please fill out this form the day of your appointment. Thank you so much for your cooperation during this time! Name* First Last Clinician(s)*Gloria Kanuka (PT)Michael Kirby (PT)Richard Chambers (PT)Dr. Jordan Sandham (DC)Kerina Sorenson (RMT)Robert Voshell (RMT)Nisha Richard (RMT)Name of the clinician(s) you will be seeing today.Have you been exposed to a confirmed, probable or suspected case of COVID-19 in the past 14-days?* Yes No Have you had a positive COVID-19 test within the last MONTH?* Yes No Are you awaiting the results of a COVID-19 test?* Yes No Do you or anyone in your household have a new or worsening COUGH?* Yes No Do you or anyone in your household have new or worsening SHORTNESS OF BREATH?* Yes No Do you or anyone in your household have a new or worsening SORE THROAT?* Yes No Do you or anyone in your household have a new or worsening LOSS OF SENSE OF TASTE OR SMELL?* Yes No Do you or anyone in your household have symptoms (such as a FEVER > 37.8°C)?* Yes No Have you had SHAKES, CHILLS, SEVERE ACHES, SEVERE HEADACHE, RUNNY NOSE, NAUSEA, DIARRHEA OR VOMITING in the past 24 hours?* Yes No In the past 14 days, have you TRAVELLED OUTSIDE OF CANADA to any other locations?* Yes No Consent I agree to the privacy policy.The information collected in this form is mandatory to commence your treatment. If you are uncomfortable disclosing this information through our website, please contact our clinic and we can offer an alternative screening method. The information collected in this form will be used for screening purposes only, to determine whether it is appropriate to commence treatment during the COVID-19 pandemic. The information will not be used in any other way and will not be disclosed to any party outside of Country Hills Physio.Signature*
