Patient Screening

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Patient Screening

Patient and Staff Screening Tool
Completion of this form is required prior to any member of the public entering the clinic to help us ensure we keep everyone safe and continue our duty to flatten the curve.

* PATIENTS (and CAREGIVERS), please complete this form on the day of your appointment, BEFORE you arrive.

* STAFF, please complete before the start of your shift.

Prior to entering the clinic please ensure you read the "re-open Procedure" to familiarize yourself with our *enhanced* physical distancing and safety procedures.

First Name *

Last Name *

Are you experiencing any of the following symptoms? *

Fever

Chronic Cough

Shortness of Breath

Sore Throat

I do not have any of the symptoms mentioned above

Required

Are you (or anyone with you today) experiencing a new onset of 2 or more of the following symptoms today? *

Headache

Fatigue or Exhaustion

Muscle Aches

Runny Nose

Nausea, Vomiting or Diarrhea

Rashes

Loss of Taste or Smell

Hoarse Voice

I do not have any of the symptoms mentioned above

Required

In the last 5 days, have you tested positive on a rapid antigen test, molecular test, or home-based self testing kit? *

Yes

Within the past 5 days, have you: **Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 metres) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.

Had close contact* with someone who is confirmed as having COVID-19, or

Had close contact* with someone with acute respiratory illness who had similar close contact with someone who is confirmed as having COVID-19, or

Had laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID-19 virus.

No, I have not had any contact or exposure.

I agree to wear a mask and sanitize my hands upon entry into Fotis Physio and Wellness for my safety, and the safety of others. *

Yes

I agree that the responses I provided are true to the best of my knowledge. I am aware of the risks of entering the clinic and I have been informed of the safety precautions that Fotis Physio and Wellness has in place. I consent to proceeding with in-person care, and having this information collected by the clinic for my safety and the safety of others. *

Yes

Thank you for your submitting your responses and helping us control the spread of COVID-19.Rest assured, as we navigate this pandemic, we are doing we are doing so in full alignment with regularly updated recommendations made by credible health authorities like the World Health Organization (WHO), the Canadian Public Health Agency, Provincial Public Health Authorities and the Regulatory Colleges.If you have any questions or concerns please contact a member of the Fotis Physio and Wellness Team.Phone: 705-985-4567

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