Patient COVID-19 Screening & Declaration
From Physiomobility - Please complete and submit this COVID-19 Screening & Declaration Form prior to attending your appointment.
Email address *
Dear Client/Visitor
Please fill in your name, appointment/visit date and answer the questions below.

We will provide in-person treatments only when no additional risk of infection to our clients or staff is perceived.
Full Name *
Phone Number *
Date of Appointment/Visit *
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Question 1: Do you or the person you are inquiring about have any of the following symptoms: severe difficulty breathing (e.g., struggling for each breath, speaking in single words), chest pain, confusion, extreme drowsiness or loss of consciousness? *
Question 2: Do you or the person you are inquiring about have shortness of breath at rest or difficulty breathing when lying down? *
Question 3: Do you have a new onset of any of 2 or more of any of the following symptoms: runny nose, muscle aches, headache, fever, chills, cough, sore throat, shortness of breath, loss of sense of taste or smell, vomiting or diarrhea for more than 24 hours? *
Question 4: In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? *
Question 5: In the last 14 days, have you been in close physical contact with a person who either: • is currently sick with a new cough, fever, or difficulty breathing? or • returned from outside of Canada in the last 2 weeks? *
Question 6: Have you traveled outside of Canada in the last 14 days? *
Question 7: In the past 14 days, have you been in a setting that has been identified as a risk for acquiring COVID-19 at a workplace such as, a long-term care center or hospital? *
Question 8: If you are a Health Care worker, are you equipped and wear complete PPE? (ie. mask, face shield/eye protection, gowns, gloves)
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**STOP**PLEASE READ**
If you have answered any of these questions as "yes", we advise that contact a doctor or Telehealth Ontario at 1-866-797-0000 to speak with a registered nurse and follow Public Health advice. Stay home and monitor your health.

For further questions/concerns and inquiries, please contact our clinic directly at 416-444-4800.
Only answer the following questions if you have previously tested positive for COVID-19
**Please carefully read and answer the following questions.**
Please provide the date of your positive test result:
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Did you quarantine for 14 days?
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Have you taken a second COVID-19 Test since?
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What was the result of your second COVID-19 test?
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