COVID-19 SCREENING QUESTIONNAIRE

It is our current policy that all patients and staff must complete this questionnaire before being allowed to enter Delta Physiotherapy & Rehab for in person therapy.

First Name

Last Name

Email Address

Phone

Date

1) Are you experiencing any of the following symptoms? Check all that apply.

Severe difficulty breathing (struggling for each breath, can only speak in single words) Severe chest pain (constant tightness or crushing sensation) Feeling confused (for example, unsure of where you are) Losing consciousness None of the above (Severe difficulty breathing, Severe chest pain, Feeling confused, Losing consciousness)

If you checked any of the symptoms in question 1, then call 911 or go directly to your nearest emergency department.

2) Do you have any of the following symptoms? Check all that apply.

Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher) Chills Cough that's new or worsening (continuous, more than usual) Barking cough, making a squeaky or whistling noise when breathing Shortness of breath Sore throat Difficulty swallowing Hoarse voice (more rough or harsh than normal) Runny nose Stuffy or congested nose Lost sense of taste or smell Headache Digestive issues (nausea/vomiting, diarrhea, stomach pain) Fatigue (lack of energy, extreme tiredness) Falling down more than usual For young children and infants: (sluggishness or lack of appetite) None of the above (Fever,Chills, Cough that's new or worsening, Barking cough, making a squeaky or whistling noise when breathing, Shortness of breath, Sore throat, Difficulty swallowing, Hoarse voice, Runny nose, Stuffy or congested nose, Lost sense of taste or smell, Headache, Digestive issues, Fatigue, Falling down more than usual, For young children and infants)

If you checked 'None of the above' then proceed to question 4.
If you checked any of the above symptoms then proceed to question 3.

3) Have you worked as a caregiver, personal support worker, or in a health care setting in the last 14 days? This includes providing care to people with or without COVID-19 symptoms.

Yes No

If you answer 'No' then proceed to question 4.
If you answer 'Yes' immediately call your primary care provider (ie family doctor) and Telehealth Ontario at 1-800-797-0000 for further instruction.
After calling you must:

Stay at home unless told to leave by a doctor or nurse.

Tell people you've been in contact with that you may have been exposed to COVID-19

Monitor your health

4) Have you travelled outside Canada in the last 14 days?

Yes No

If you answer 'No' then proceed to question 5.
If you answer 'Yes' you must self-isolate for 14 days immediately after your return to Canada. You do not need to contact a doctor or Telehealth Ontario for an assessment

Stay at home for 14 days

Monitor your health

5) Has someone you're in close contact with (household or workplace) tested positive for COVID-19?

Yes No

If you answer 'No' then proceed to question 6.
If you answer 'Yes' you must self-isolate for 14 days immediately after your return to Canada. You do not need to contact a doctor or Telehealth Ontario for an assessment.

Stay at home for 14 days

Monitor your health

6) Are you in close contact with a person who either:

is sick with new respiratory symptoms (can include fever, cough or difficulty breathing) recently travelled outside Canada none of the above

If you checked 'none of the above' in question 6, you are allowed to enter Delta Physiotherapy & Rehab.

If you did check any option other than 'none of the above' in question 6, you must stay at home for 14 days because you were in close contact with someone who either recently travelled, tested positive for COVID-19, or has new respiratory symptoms. You do not need to contact your doctor or Telehealth Ontario.

Stay at home for 14 days

Monitor your health

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