CONFIDENTIAL CLIENT COVID-19 PRE-SCREENING FORM

CONFIDENTIAL CLIENT COVID-19 PRE-SCREENING FORM

Client First and Last Name:

Date

Phone Number:

PLEASE FILL OUT THIS FORM AND RETURN IT TO YOUR THERAPIST NO LESS THAN 24 HOURS BEFORE YOUR APPOINTMENT. IF YOUR CONDITION CHANGES FROM THE TIME THAT YOU SUBMIT THIS FORM, INFORM YOUR THERAPIST BEFORE YOUR APPOINTMENT TIME.

Current temperature if known (this field is recommended, but not required):

in adults: 38°C (100.4°F) and above (oral temperature),
in older adults: 37.8°C (100°F) and above (oral temperature),
in children: 38°C (100.4°F) and above
or 1.1°C above the person's usual value

Do you have a fever?

YESNO

Are you experiencing any of the following? • shortness of breath at rest • inability to lie down because of difficulty breathing • chronic health conditions that you are having difficulty managing because of your current respiratory illness

YESNO

Are you experiencing any of the following? • severe difficulty breathing (e.g., struggling for each breath, speaking in single words) • severe chest pain • having a very hard time waking up • feeling confused • lost consciousness

YESNO

Do you have any of the following? • fever • new onset of cough or worsening of chronic cough • new or worsening shortness of breath • new or worsening difficulty breathing • sore throat • runny nose

YESNO

Do you have any of the following? • chills • painful swallowing • stuffy nose • headache • feeling unwell, fatigue or severe exhaustion • nausea, vomiting, diarrhea or unexplained loss of appetite • loss of sense of smell or taste • conjunctivitis (pink eye)

YESNO

In the past 14 days, did you return from travel outside of Canada, or did you have close contact with someone who is confirmed as having COVID-19?

YESNO

If you answered yes to any of these questions you are contraindicated to receive massage or manual osteopathic treatment. You must call to cancel your appointment and you may need to self-isolate. It is recommended that you immediately contact your local health authority and follow their instructions.

You have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.

Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.

Practice good hygiene: wash hands often, cover coughs and sneezes, and avoid touching your face.

Monitor for COVID-19 symptoms: fever, cough, shortness of breath, sore throat or runny nose.

If you develop any Covid-19 symptoms, stay home and take this self-assessment again.

In order to protect yourself, your therapist, and others, honest disclosure is essential.

Form Completed By:

Print Name

Signature

Date:

Date