Name *

First Name

Last Name

Appointment Date *

MM

DD

YYYY

Appointment Time *

Hour

Minute

Second

AM PM

New or worsening cough *

Yes

No

Shortness of breath *

Yes

No

Sore throat *

Yes

No

Running nose, sneezing, or nasal congestion *

(in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)

Yes

No

Hoarse voice *

Yes

No

Difficulty swallowing *

Yes

No

New smell or taste disorder(s) *

Yes

No

Nausea/ Vomiting, diarrhea, abdominal pain *

Yes

No

Unexplained fatigue/malaise *

Yes

No

Chills *

Yes

No

Headache *

Yes

No

Fever *

Yes

No

Have you previously contracted the COVID-19 virus? *

Yes

No

Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days? *

Yes

No

Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19? *

Yes

No

If you answered 'YES' to the above question: Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19?

If you answered 'NO' to the above question, you may skip this.

Yes

No

I verify that I have read and understand the above statement.

REQUIRED FOR MASSAGE PATIENTS ONLY.

Yes

No

I confirm that I have read and understand the above statement.

REQUIRED FOR MASSAGE PATIENTS ONLY.

Yes

No