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.



First and Last Name *
Are you experiencing: new or worsening severe difficulty breathing, severe chest pain, difficulty waking up, confusion or losing consciousness? *
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? *
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? *
Are you, or anyone in your household, experiencing a fever (higher than 38 degrees C) or chills? *
Are you, or anyone in your household, experiencing difficulty breathing, a cough and/or a loss of smell or taste? *
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 *
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. *
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. *
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. *
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