COVID-19 Screening

Ministry of Health COVID-19 Patient Screening Guidance Document V. 5.0, August 26, 2021

This screening tool is based on the latest COVID-19 case definitions and the Coronavirus disease (COVID-2019) situation reports published by the World Health Organization. This document should be used to screen people who are suspected or confirmed of having COVID-19 throughout the health and emergency response system. Ensuring all health and safety providers are following the same screening protocol will help ensure consistency when dealing with suspected or confirmed cases of COVID-19.

Your Name *

First

Last

Email *

In order to ensure the health and safety of our patients and staff, you are required to complete the Ontario Public Health COVID-19 screening tool. Please read through the screening questions below and at the end of the document indicate your selection.

Q1: Have you received your final (or second) vaccination dose more than 14 days ago? *

Q2: 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 • If adult >18 years of age: unexplained fatigue/ / / lethargy malaise muscle aches (myalgias) • If child <18 years of age: nausea/vomiting, diarrhea *

Q3: Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *

Q3: If you answered no to question 1, have you traveled outside of Canada in the past 14 days *

Q4: If you answered no to question 1, have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

By selecting the "Submit" button, I acknowledge that I have answered the above questions honestly. I acknowledge that I am signing this screening electronically. I agree that my electronic signature on this document is the equivalent of my manual/handwritten signature.

Family Physiotherapy

COVID-19 Screening

Ministry of Health COVID-19 Patient Screening Guidance Document V. 5.0, August 26, 2021

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