Skip to content
Search for:
Home
Telehealth
Locations
Beamsville Clinic Information
St. Catharines Clinic Information
Services
Chiropractic
Physiotherapy
Massage Therapy
Athletic Therapy
Personal Training
Spinal Decompression
Acupuncture
Patient Resources
Patient Forms
Blog
Videos
Exercises
FAQ
Contact
Contact Beamsville
Contact St. Catharines
Appointment Pre-Screening
Covid-19 Pre-Screening Assessment Tool
Home
•
Covid-19 Pre-Screening Assessment Tool
Covid-19 Pre-Screening Assessment Tool
CornerstoneTW
2020-05-28T00:26:52+00:00
Please answer the following questions the day of your appointment.
Please enable JavaScript in your browser to complete this form.
Name
*
First and Last Name
Email Address
*
Date of Appointment
*
(DD/MM/YYYY)
Do you have the following symptoms or signs? Check all that apply.
*
New or Worsening Cough
Fever
Shortness of breath
Sore Throat, Runny Nose, Sneezing, Nasal Congestion (not including allergy symptoms)
Hoarse Voice
Difficulty Swallowing
New Smell of Taste Disorder
Nausea/Vomitting, Diarrhea, Abdominal Pain
Unexplained fatigue/malaise
Chills
Headache
NONE
2. Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)?
*
Yes
No
3. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19 within the last 10 days?
*
Yes
No
** Examples include: A positive test from a co-worker that you have been around in the last 10 days or being around a family member with flu/cold like symptoms in the last 10 days.
5. Are you or someone you live with awaiting the results of a Covid-19 test?
*
Yes
No
In Person Treatment Consent
*
I acknowledge and understand the presumed risk of having in person therapy.
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). Exposure to Covid-19 may result in adverse health effects that may require hospitalization, intubation/ventilator support, long-term health related risks (i.e lung dysfunction), or even death.
Message
Submit
Go to Top