Screen Questionnaire - EQ PHYSIO - Oakville, ON Our forms require Javascript for functionality. If you are seeing this message then Javascript is disabled. Below are links to instructions on how to enable JavaScript in the most commonly used browsers. Google Chrome Apple Safari Mozilla Firefox Microsoft Edge Internet Explorer Opera "*" indicates required fields Name* First Last Email* Appointment Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of person you are accompanying (if not applicable type NA)* Please answer Yes or No. If you answer “Yes” to any question, please inform us at the office Info@EQPhysio.com / Tel: 905-599-6478) and do not come for your session. 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* Yes No 2) In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions), Respond = "No."Your answer for Question 2 is* Yes No 3) In the last 5 days have you experienced any of these symptoms? Respond “NO” if all of these apply: You have completed your isolation period of 5 days or you tested negative for COVID‐19 on one PCR test or rapid molecular test or two rapid antigen tests taken 24 to 48 hours apart, and You do not have a fever, and Your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea) 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- Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have) Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have) Decrease or loss of taste or smell - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have Muscle aches/joint pain- Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have) Extreme tiredness - Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) Sore throat - Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have) Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have Headache - New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have) Nausea, vomiting and/or diarrhea - Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have. Your answer for Question 3 is* Yes No 4) 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 4 is* Yes No 5) In the last 5 days, have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit? Respond "NO" if you have already completed your isolation period of 5 days because your symptoms started before your positive test result, and: You do not have a fever, and Your symptoms have been improving for 24 hours (48 hours for nausea, vomiting, and/or diarrhea) Your answer for Question 5 is* Yes No 6) Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.Your answer for Question 6 is* Yes No EmailThis field is for validation purposes and should be left unchanged.
