Client/Patient Screening COVID-19 Questionnaire Name* First Last Email* Enter Email Confirm Email Position/Company* 1. Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?* Yes No 2. Did you have close contact with anyone with acute respiratory illness OR traveled outside of Canada in the past 14 days?* Yes No 3. Do you have a confirmed case of COVID-19 OR had close contact with a confirmed case of COVID-19?* Yes No 4. In the last 14 days have you been in quarantine?* Yes No 5. In the last 14 days, were you directed to self-isolate by a medical professional?* Yes No 6. Do you have any two (2) or more of the following symptoms: Sore throat Hoarse voice Difficulty swallowing Decrease or loss of taste or smell Chills Headaches Unexplained fatigue/malaise Diarrhea Abdominal pain Nausea/vomiting Pink eye (congunctivitis) Runny nose/sneezing without other known cause Nasal congestion without other known cause If you answered Yes to any of the above questions, please provide more detail below.Date:I certify that the above statements are true and understand if I falsify any of the above information, I could be putting other people at risk.*Initial I also certify that I understand there are inherent risks of having my healthcare provider conduct my or my child’s visit in my home.*Initial I agree to the inherent risks for possible breaches in privacy and confidentiality if myself and my therapist choose to conduct a session outdoors.*Initial I understand and agree to comply with the COVID-19 policy.*Initial Recommended – Not Required Personal Protective EquipmentMask* Accepted, and worn on this occasion Declined Gloves* Accepted, and worn on this occasion Declined SignatureDate MM slash DD slash YYYY