Patient COVID-19 Screening Tool
Completion of this form is required prior to members of the public and our staff entering the clinic to help us ensure we keep everyone safe and continue our duty to flatten the curve.
* PATIENTS (and any CAREGIVER needed to accompany a patient), please complete this form on the day of your appointment, BEFORE you arrive.
* Required
First and Last Name
*
Your answer
Are you experiencing: new or worsening severe difficulty breathing, severe chest pain, difficulty waking up, confusion or losing consciousness?
*
Yes. Do not come to the clinic. Please immediately call 911 or go directly to the Emergency Department.
No. I do not have any of the above mentioned symptoms
Are you experiencing a new onset of: mild to moderate shortness of breath, inability to lie down because of difficulty breathing or chronic health conditions that you are having difficulty managing because of difficulty breathing?
*
Yes. Do not come to the clinic. Consult a medical doctor, a Nurse Practitioner or call 811.
No. I do not have any of the above mentioned symptoms
In the last 14 days have you, or anyone in your household, tested positive (or are awaiting test results) for COVID-19, or been exposed to someone with confirmed COVID-19 or travelled outside of Canada?
*
Yes. Do not come to the clinic. Cancel your appointment. Follow direction from Public Health and self-isolate.
Yes but I am a Health Care Worker and I was wearing appropriate PPE so exposure risk was reduced.
No
Are you, or anyone in your household, experiencing a fever (higher than 38 degrees C) or chills?
*
Yes. Do not come into the clinic. Consult a medical doctor, Nurse Practitioner or call 811. Arrange immediate COVID-19 testing.
No. I do not have a fever or chills
Are you, or anyone in your household, experiencing difficulty breathing, a cough and/or a loss of smell or taste?
*
Yes. Do not come into the clinic. Consult a medical doctor, or Nurse Practitioner or call 811. Arrange immediate COVID-19 testing.
No. I do not have any of the above mentioned symptoms.
Are you, or anyone in your household, experiencing any potentially COVID-19 related symptoms? (including symptoms following a recent vaccination) These include: • Sore Throat • Headache • Extreme fatigue or tiredness • Diarrhea • Loss of Appetite • Nausea, Vomiting • Body aches
*
Yes. Do not come to the clinic. Postpone further appointments until you feel better. Call 811 and/or complete the BC COVID Screening Tool
https://bc.thrive.health/covid19/en
and follow the directions given.
No. I do not have any of these symptoms
I agree that when I enter Kamloops Physiotherapy I will perform proper hand washing, wear a mask, maintain physical distancing as directed and follow all other guidelines as directed for my safety, and the safety of others.
*
Yes
No
I am aware that when I leave my home there is a risk of being exposed to the coronavirus and possibly developing COVID-19. I have been informed of the safety precautions that Kamloops Physiotherapy and Sports Injury Centre has in place. I understand that a video visit with a physiotherapist or kinesiologist (Tele-Rehabilitation) is an option offered by Kamloops Physiotherapy if I prefer to stay at home.
*
Yes I choose to attend Kamloops Physiotherapy and consent to proceeding with my appointment.
No
I agree that the responses I have provided are true to the best of my knowledge. I consent to having this information collected by the clinic. I understand that information may be shared with public health for appropriate contact tracing.
*
Yes
No
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