905-582-9700 info@palermophysio.ca

Covid Screening Questionnaire

Screening Questionnaire for Covid-19 Symptoms that must be filled out before each appointment.

Name*
First Last
Phone*
Email*
1. Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?*
- Yes
- No
2. Have you had any close contact with anyone with acute respiratory illness OR travelled outside of Canada in the past 14 days?*
- Yes
- No
3. Do you have a confirmed case of COVID-19 OR had close contact with a confirmed case of COVID-19?*
- Yes
- No
Do you have any of the following symptoms? (Check all that apply)*
- Sore throat
- Hoarse Voice
- Difficulty swallowing
- Decreased or loss sense of smell or taste
- Chills
- Headache
- Unexplained fatigue / malaise
- Diarrhea
- Abdominal pain
- Nausea/ Vomiting
- Pink eye (conjunctivitis)
- Runny nose / sneezing (without other known cause)
- Nasal congestion (without other known cause)
- None of the above
If you are 65 years of age or older, are you experiencing any of the following?
- Delirium
- Unexplained or increased number of falls
- Acute functional decline or worsening chronic conditions
- None of the Above
Consent*
I agree that this information is accurate and true.
Name
This field is for validation purposes and should be left unchanged.

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