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1
COVID-19 Health Screen/Declaration Form

Dear Client/Staff/Visitor


Please fill in your name and date and answer the questions below. 

We will provide in-person treatments only when no additional risk of infection to our clients or staff is perceived.

Your Full Name
Your Phone number
Date of visit
Questions
Question 1: Do you or the person you are inquiring about have any of the following symptoms: severe difficulty breathing (e.g., struggling for each breath, speaking in single words), chest pain, confusion, extreme drowsiness or loss of consciousness?
Answer 1:
Please call 911 or go directly to your nearest Emergency Department.
Question 2: Do you or the person you are inquiring about have shortness of breath at rest or difficulty breathing when lying down?
Answer 2:
Contact a doctor or Telehealth Ontario at 1-866-797-0000 to speak with a registered nurse and follow Public Health advice. Stay home and monitor your health.
Question 3: Do you have a new onset of any of 2 or more of any of the following symptoms: runny nose, muscle aches, headache, fever, chills, cough, sore throat, shortness of breath, loss of sense of taste or smell, vomiting or diarrhea for more than 24 hours?
Answer 3:
Contact a doctor or Telehealth Ontario at 1-866-797-0000 to speak with a registered nurse and follow Public Health advice. Stay home and monitor your health.
Question 4: In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?
Answer 4:
Based on your answers, we recommend that you stay at home for 14 days because you were in close physical contact with someone who has COVID-19 symptoms or recently traveled.
Question 5: In the last 14 days, have you been in close physical contact with a person who either:

• is currently sick with a new cough, fever, or difficulty breathing? or
• returned from outside of Canada in the last 2 weeks?
Answer 5:
Based on your answers, we recommend that you stay at home for 14 days because you were in close physical contact with someone who has COVID-19 symptoms or recently traveled.
Question 6: Have you travelled outside of Canada in the last 14 days?
Answer 6:
Based on your answers, we recommend that you stay at home for 14 days because you were in close physical contact with someone who has COVID-19 symptoms or recently traveled.
Question 7: In the past 14 days, have you been in a setting that has been identified as a risk for acquiring COVID-19, such as on a flight, at a workplace, long-term care center or hospital?
Answer 7:
Based on your answers, we recommend that you stay at home for 14 days because you were in close physical contact with someone who has COVID-19 symptoms or recently traveled.

You answered No to all questions above.


Based on this responses you can provide or receive in-person treatment or accompany a client to our facility. Physiomobility Health Group closely follows municipal & provincial public health guidelines. However, this practice does not eliminate the risk of exposure to infection. 


If you develop symptoms of a respiratory illness (e.g. fever, cough, runny nose, sore throat), Contact a doctor or Telehealth Ontario at 1-866-797-0000 to speak with a registered nurse and follow Public Health advice. You may be eligible for a COVID-19 test.


Please call our office and cancel your in-person appointment. We will your provide treatment through virtual physiotherapy.

If you are in any of at-risk groups, we recommend you stay home. We gladly provide you with in-home or online treatments.


  • 65 years old or older
  • Pregnant or recently gave birth
  • Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids,TNF inhibitors)
  • Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, other autoimmune disorder)
  • Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition)
  • Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)
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