COVID-19 Screening Tool
This tool is to help keep our staff and clients healthy. Please fill it out and submit it on the same day as your appointment, prior to coming to the office. If you answer yes to any of these questions, DO NOT come to your appointment. You may qualify to be tested for COVID-19 by calling 811.
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Please put in the first and last initials of the person who the appointment is for and the date and time of the appointment *
Do you or your child have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, runny nose, aches and pains, headache, loss of taste or smell, or skin rash. * *
If you have a thermometer, please take your (and your child's) temperature on the morning of your appointment and share it below.  Body temperature over 38 degrees C or 100 F indicates a fever. DO NOT come to the office if you are experiencing a fever. *
Have you returned to Canada from outside the country (including USA) in the last 14 days? * *
In the last 14 days did you have close contact* with someone who has a probable** or confirmed case of COVID-19? * *
In the last 14 days did you have close contact* with a person who had acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID-19? * *
In the last 14 days did you have close contact* with a person who had acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick? * *
Note: What is Close Contact* and Probable** Case?
*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters/6 feet) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.

**Probable case is a person with clinical illness who had close contact to a lab-confirmed COVID-19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID-19 exposure criteria, AND in whom laboratory diagnosis of COVID-19 is inconclusive.

Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose.

Exposure Criteria for a probable case is a person who, in the 14 days before onset of illness,

» had any history of travel outside Canada; OR» had close contact with a confirmed or probable case of COVID-19; OR

» is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR

» had laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID-19.
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