Screen Questionnaire - EQ PHYSIO - Oakville, ON Step 1 of 3 33% Name* First Last Email Appointment DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of person you are accompanying (if applicable) 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 isYesNo2) Are you currently experiencing any of these symptoms? Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher) Chills Cough that's new or worsening (continuous, more than usual) Barking cough, making a whistling noise when breathing (croup) Shortness of breath (out of breath, unable to breathe deeply) Sore throat Difficulty swallowing Runny nose (not related to seasonal allergies or other known causes or conditions) Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions) Lost sense of taste or smell Pink eye (conjunctivitis) Headache that’s unusual or long lasting Digestive issues (nausea/vomiting, diarrhea, stomach pain) Muscle aches Extreme tiredness that is unusual (fatigue, lack of energy) Falling down often For young children and infants: sluggishness or lack of appetite Your answer for Question 2 isYesNo3) Are you in any of these at-risk groups? 70 years old or older 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) Your answer for Question 3 isYesNo 4) In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? Close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes Living in the same home Your answer for Question 4 isYesNo5) 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? Returned from outside of Canada in the last 2 weeks? Close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes Living in the same home Your answer for Question 5 isYesNo6) Have you travelled outside of Canada in the last 14 days?Your answer for Question 6 isYesNo
