KINESIS PHYSIOTHERAPY & REHABILITATION CENTRE COVID SCREENING QUESTIONNAIRE
Patient Name
*
Date
*
Have you received your final (or second) vaccination dose more than 14 days ago?
Yes
No
Do you have any of the following symptoms?
Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
Unexplained fatigue
Lethargy and muscle aches
If a child – Nausea, Diarrhea, Vomiting
Yes
No
Have you been tested positive for COVID-19 in the past 10 days or told to isolate?
Yes
No
Did you travel outside of Canada in the past 14 days?
Yes
No
Have you come in close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Yes
No
Signature
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