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Pre-screening Questionnaire

This declaration must be completed at least one hour before, and on the day of the practice that participant(s), and anyone else accompanying the participant and entering the facility, plans to attend. The names of ALL people entering the facility must be entered on this form, or a separate form must be completed.

*New or modified criteria added on 2021-03-04*

Please review the following symptoms, and consider whether any of the people participating or planning on entering the facility would answer yes to any of the following:
  • Do you have a fever, onset of a new cough, worsening of a chronic cough, shortness of breath, or difficulty breathing?
  • Have you been in contact with anyone with acute respiratory illness, or who has traveled outside of Canada in the last 14 days?
  • Have you *or anyone you live with* traveled outside of Canada or the Province of Ontario in the last 14 days?
  • *Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*
  • Do you have a confirmed case of COVID-19 or been in contact with a person who has had a confirmed case of COVID-19?
  • *Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*
  • *In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?*
  • *In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?*
  • Do you have one or more of the following symptoms:
    • Fever?
    • Chills?
    • Cough that's new or worsening?
    • Barking cough, making a whistling noise when breathing?
    • Shortness of breath?
    • Sore throat or hoarse voice?
    • Difficulty swallowing?
    • Runny *or stuffy* nose / sneezing without other known cause?
    • Stuffy or congested nose?
    • Decrease or lost sense of taste or smell?
    • Pink eye (conjunctivitis)?
    • Headache that's unusual or long lasting?
    • Digestive issues like nausea/vomiting, diarrhea, stomach or abdominal pain?
    • Muscle aches that are unusual or long lasting?
    • Extreme tiredness that is unusual?
    • Falling down often?
1. Do any of the people planning to attend and enter the facility answer yes to any of the above questions? *This question is required.
Please do not attend practice. You should consult your medical physician or contact Telehealth.