Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone - please tell us the # we can use to call you on the day of your appointment, prior to your visit *

(###)

###

####

Scheduled Treatment Date

(FOR YOU OR PERSON YOU'RE ACCOMPANYING)

MM

DD

YYYY

1. a) In the past 14 days, have you been in close contact with anyone with acute respiratory illness? *

YES

NO

1. b) In the past 14 days, have you travelled outside of Ontario? *

YES

NO

2. a) Do you have a confirmed case of Covid-19? *

YES

NO

2. b) In the past 14 days, have you had close contact with a confirmed case of Covid-19? *

YES

NO

3. DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS? *

Please select ALL that apply

Fever

New onset of cough

Worsening of 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

I DO NOT HAVE ANY OF THE ABOVE SYMPTOMS

4. Are you 70 years of age or older? *

Yes

No

IF YOU ARE OVER 70, PLEASE INDICATE WHETHER YOU'RE EXPERIENCING THE SYMPTOMS BELOW

- Delirium

- Unexplained or increased number of falls

- Acute functional decline

- Worsening of chronic conditions

I AM 70 OR OLDER, AND I AM NOT EXPERIENCING ANY OF THE 4 SYMPTOMS LISTED ABOVE

I CERTIFY THAT MY ANSWERS ARE TRUE AND CORRECT *

YES