COVID-19 Protocols - Pre-Treatment Screening

First Name *

Last Name *

You are required to complete this questionnaire no more than 24 hours prior to your appointment date/time, and are advised that you may not receive treatment if you are feeling unwell at the time of the appointment.

You are further advised to use the 811 on-line self-assessment if you are unwell at https://811.novascotia.ca.

You are asked to answer the following questions by checking the appropriate response:

1 - Have you tested positive for COVID-19 that you have not fully recovered from? *

NoYesNo

2 - Are you experiencing a fever (ie. chills, sweats?) *

NoYesNo

3 - Are you experiencing a cough, or worsening of a previous cough? *

NoYesNo

4 - Are you experiencing a sore throat and/or a hoarse voice? *

NoYesNo

5 - Are you experiencing sneezing, nasal congestion and/or runny nose? *

NoYesNo

6 - Are you experiencing shortness of breath? *

NoYesNo

7 - Are you experiencing an unusual increase in frequency or intensity of headaches? *

NoYesNo

8 - Are you experiencing unusual or unexplainable fatigue? *

NoYesNo

9 - Are you experiencing a loss of sense of smell or taste? *

NoYesNo

10 - Have you traveled outside of Nova Scotia within the last 14 days? *

NoYesNo

11 - In the last 14 days, have you been in close physical proximity to anyone who has traveled outside Nova Scotia? *

NoYesNo

14 - Have you had unprotected close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 infection? (eg. individuals exposed without appropriate PPE in use) *

NoYesNo

By my signature, I attest that the answers I have given to the above questions are true to the best of my knowledge.

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

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COVID-19 Protocols - Pre-Treatment Screening

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