Triage Questionnaire for Covid-19 before an Acupuncture Appointment
On the day prior to your acupuncture appointment, please fill out this triage questionnaire. This action is required by the Professional Order of Acupuncturists of Quebec. It is part of the new measures put in place to limit the propagation of Covid-19.

If you prefer, you can also download a PDF version of the questionnaire, or answer these questions by phone.
- Questionnaire in PDF format available at www.acupunctureKM.com/covid19
- To contact me by phone : 514-274-5970

If you have already answered this form for a previous acupuncture session with Kathleen McMeekin and your answers have not changed since then, you do not need to refill this questionnaire.
IN THE LAST 14 DAYS:
1- Are you currently in a mandatory isolation period? *
("in quarantine")
2- Do you have flu-like symptoms: fever, cough, breathing difficulties? *
3- Do you have a sudden loss of smell without nasal congestion, with or without loss of taste? *
4- Do you have at least two of the following symptoms: muscle pain, headache, extreme fatigue, severe loss of appetite COMBINED WITH a sore throat or diarrhea? *
5- Have you been in close contact with someone who traveled outside Canada and his/her mandatory isolation has not ended ? *
6- Do you live under the same roof or do you have intimate relations with a confirmed Covid19 person and his/her mandatory isolation period has not ended? *
7 - Did you provide body care service in a non-medical setting for a confirmed Covid-19 case (e.g.at home)? *
8- Did you have direct contact with infectious body fluids of the person? *
(e.g. you have received sputum on the face when people have coughed or sneezed, etc.)
9- Were you in a prolonged contact (at least 15 minutes or according to the risk assessment) and less than 2 meters without protection (mask) with a confirmed Covid19 case? *
If you answer NO to all of these questions: the acupuncturist can proceed with the treatment.
• Wash your hands according to the instructions:
- when entering and leaving the clinic.
- after going to the toilet.
• Wear a mask
• Respect the 2 metre distance in the waiting room.
• Pay attention to the instructions given by the acupuncturist.
• Implement the hygiene and respiratory etiquette measures:
- cough or sneeze into your elbow.
- throw the tissues in the trash.
- wash your hands after a risk of contact with respiratory secretions or saliva.
• Avoid touching unnecessary objects and moving around the clinic.
You answer “YES” to one of these questions: the acupuncturist cannot proceed with the treatment. 1. Reschedule your appointment. 2. Wash your hands according to the instructions. 3. Wear a mask. 4. Return to your home. 5. Contact 1 877 644-4545
If you answered YES to any of these questions: the acupuncturist cannot proceed with the treatment.
1. Reschedule your appointment. (Contact the acupuncturist for more information if necessary.)
2. Wash your hands according to the instructions.
3. Wear a mask.
4. Return to your home.
5. Contact 1 877 644-4545
I hereby declare that the above information is true and correct and I agree to apply the infection prevention and control measures indicated above. I agree to inform the acupuncturist of any change in my condition related to COVID-19 – A VERBAL VALIDATION WILL BE REQUIRED AT EACH VISIT *
YOUR NAME AND SURNAME
Signature (during the appointment): _____________________________________________________________
(This form will be printed and added to your acupuncture file. You can sign it in person during your appointment.)
Date: *
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