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Appointment Pre-Screening

Appointment Pre-Screening

Name*

Email Address*

Date of Appointment *

1. Do you have any of the following symptoms?:

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of smell or taste

Chills

Headaches

Unexplained fatigue/malaise/muscle aches (myalgias)/lethargy

Nausea/vomiting/diarrhea/abdominal pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion (not including allergy symptoms), hoarse voice

Yes

2. Has a Doctor, Healthcare Provider, or Public Health Unit told you that you should currently be isolating or staying at home?

Yes

3. Have you come into close contact with anyone with a respiratory illness or a confirmed case of COVID 19 within the last 10 days?

Yes

4. Are you or someone that you live with awaiting the results of a COVID-19 test?

Yes

5. Are you 70 years of age or older?

Yes

6. If you are 70 years of age or older, are you experiencing any of the following symptoms?

Delirium

Unexplained or increased number of falls

Acute functional decline

Worsening of chronic conditions

Yes

Thanks for submitting!

This checklist provides basic information only and contains recommendations for COVID-19 screening. The screening result is not equivalent to a confirmed diagnosis of COVID-19.

Please fill the following form before your appointment at the Pelham Chiropractic & Wellness Centre in St. Catharines:

If the response to ALL of the screening questions is NO	COVID Screen Negative
If the response to ANY of the screening questions is YES	COVID Screen Positive