Screen Questionnaire - EQ PHYSIO - Oakville, ON

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Name*
Appointment Date*

Please answer Yes or No.

If you answer “No” to all the questions, please email us back at Info@EQPhysio.com with the subject line “ALL CLEAR.”

If you answer “Yes” to any question, please inform us at the office.

Please also let us know if you are:

  • Immunocompromised (for this question, factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised)
    • Examples of being immunocompromised include those:
      • Undergoing cancer chemotherapy
      • With untreated HIV infection with CD4 T lymphocyte count less than 200
      • With combined primary immunodeficiency disorder
  • On prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days
  • On other immune suppressive medications

1. Are you currently experiencing any of these issues? Call 911 if you are.

  • Severe difficulty breathing
    (struggling for each breath, can only speak in single words)
  • Severe chest pain
    (constant tightness or crushing sensation)
  • Feeling confused or unsure of where you are
  • Losing consciousness
Your answer for Question 1 is*

2. Do you have any of these symptoms?

Respond “NO” if none of these apply:

Respond “YES” if any symptoms below apply to you that are new, worsening, and not related to other known causes or conditions you already have.

  • Fever and/or chills
  • Cough - Not related to other known causes or conditions (for example, chronic obstructive pulmonary disease)
  • Shortness of breath - Not related to other known causes or conditions (for example, asthma, chronic obstructive pulmonary disease, chronic heart failure)
  • Decrease or loss of taste or smell - Not related to other known causes or conditions (for example, nasal polyps, allergies, neurological disorders)
  • Muscle aches or joint pain - Not related to other known causes or conditions (for example, getting a COVID-19 vaccine and/or flu shot in the last 48 hours, osteoarthritis, fibromyalgia)
  • Extreme tiredness - General feeling of being unwell, lack of energy and not related to other known causes or conditions (for example, getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, anemia, malignancy)
  • Sore throat - Painful swallowing or difficulty swallowing, not related to other known causes or conditions (for example, post-nasal drip, acid reflux)
  • Runny or stuffy/congested nose - Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather, chronic sinusitis)
  • Headache - Not related to other known causes or conditions (for example, getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines)
  • Nausea, vomiting and/or diarrhea - Not related to other known causes or conditions (for example, transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effects of medication)
  • Abdominal pain - Not related to other known causes or conditions (for example, menstrual cramps, gastroesophageal reflux disease)
  • Pink eye - Not related to other known causes or conditions (for example, blepharitis, recurrent styes)
  • Decreased or no appetite (young children only) - Not related to other known causes or conditions (for example, anxiety, constipation)
  • None of the above
Your answer for Question 2 is*

3. Do any of the following apply?

  • You live with someone who is currently isolating because of a positive COVID-19 test
  • You live with someone who is currently isolating because of COVID-19 symptoms
  • You live with someone who is isolating while waiting for COVID-19 test results
Your answer for Question 3 is*

4. Have you been told that you should currently be quarantining, isolating or staying at home?

Could include being told by a doctor, health care provider, public health unit, federal border agent or other government authority.

Your answer for Question 4 is*

5. In the last 10 days, have you tested positive for COVID‐19?

This includes a positive COVID‐19 test result on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit.

Your answer for Question 5 is*
This field is for validation purposes and should be left unchanged.