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FORMS

SCREENING QUESTIONNAIRE

Shelburne Physiotherapy In Clinic Appointment COVID-19 Self Assessment Screening Questionnaire

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Have you had close contact with anyone who has acute respiratory illness OR travelled outside Ontario in the past 14 days?
Do you have a confirmed case of COVID-19 OR have you had close contact with a confirmed case of COVID-19?
Do you have any of the following symptoms?
If you are over the age of 70 are you experiencing any of the following symptoms: delirium unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

If you responded YES to any of the above questions please consider speaking with your MD/local public health authorities and/or delay your appointment until you have isolated and become symptom free or are tested for COVID.

Thanks for submitting!

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