COVID-19 Screening Form

True Health Chiropractic COVID-19 Screening Form

To prevent the spread of COVID-19 and reduce the potential exposure to our staff, patients and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in our office, and is necessary to meet guidelines issued by Public Health.

Instructions

This questionnaire is to be completed by our adult patients who are 18 years of age and older. Please complete this questionnaire 24-48 hours before the scheduled appointment. For patients under 18, a parent or guardian may fill in the form on their behalf.

Fields marked with an * are required

Patient's Information

Please answer the following questions:
Have you, the patient, received your final or second COVID-19 vaccination dose more than 14 days ago? *
Do you, the patient, have one or more of the following symptoms? *
Have you, the patient, been tested positive for COVID-19 in the past 10 days or have been told you should be isolating? *

If you answered NO to Question 1, then please answer the following two questions:
Have you, the patient, travelled outside of Canada in the past 14 days?
Have you, the patient, had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Person Completing the Questionnaire
What is your relationship to the patient? *

I have answered this questionnaire accurately. I fully understand that if I, the patient, experience respiratory illness symptoms prior to or within fourteen (14) days after my appointment, I will call True Health Chiropractic, 905-876-0048.