Covid-19 Screening Questionnaire

Covid-19 Screening

You Must Have a Negative Answer to Each and Every Question Before Your Treatment

Ontario Ministry of Health Covid-19 Screening Questionnaire (adapted)
Q1: Do you live or work in a Long-Term Care facility or Retirement Home?
Q2: Did you travel outside of Canada in the past 14 days?
Q3: Have you tested positive for COVID-19 or had close contact with a confirmed
case of COVID-19?
Q4: Do you have any of the following symptoms?
• Fever
• New onset of cough
• Worsening chronic cough
• Shortness of breath
• Difficulty breathing
• Sore throat
• Difficulty swallowing
• Decrease of loss of sense of taste or smell
• Chills
• Headaches
• Unexplained fatigue/malaise/muscle aches (myalgias)
• Nausea/vomiting, diarrhea, abdominal pain
• Pink eye (conjunctivitis)
• Runny nose or nasal congestion without other known cause
Q5: If you are 70 years of age or older, are you experiencing any of the following
• Delirium
• Unexplained or increased number of falls
• Acute functional decline
• Worsening of chronic conditions
COVID-19 Screening Results:
If response to ALL of the screening questions is NO: COVID Screen Negative. You can come to our clinic to receive acupuncture/TCM treatments. Thank you for your cooperation.