COVID19 Screening Questions Please answer the following COVID19 Screening Questions.Legal Name* First Last Name you go by (if different than above) First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Are you currently experiencing 1 or more of the symptoms that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. Fever and/or chills (37.8C/100F or higher), cough or barking cough, shortness of breath, sore throat or difficulty swallowing, decrease or loss of smell or taste, pink eye, runny or stuffy/congested nose*YesNo2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*YesNoThis can be because of an outbreak or contact tracing.3. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?*YesNoIf you have since tested negative on a lab-based PCR test, select “No.4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?*YesNoIf it's been more than 14 days since your 2nd dose and are fully vaccinated, and have not been advised to self-isolate by public health, select “No”.5. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?*YesNoIf it's been more than 14 days since your 2nd dose and are fully vaccinated and/or have already gone for a test and got a negative result, select "No."6. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*YesNoSee federal quarantine requirements here: https://travel.gc.ca/travel-covid#a37. Is anyone you live with currently experiencing any new COVID -19 symptoms and/or waiting for test results after experiencing symptoms?*YesNoIf it's been more than 14 days since your 2nd dose and are fully vaccinated, select “No.” If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”**If you answered YES to ANY of the above questions we will have to reschedule your appointment, for the safety of our staff and other patients. At the direction of public health, you should stay home, self-isolate immediately and contact your health care provider or Telehealth Ontario (866-797-0000) to get advice or an assessment.**If you answered YES to question 7, you must stay home, along with the rest of the household, until the sick individual gets a negative COVID-19 test result, is cleared by their local public health unit, or is diagnosed with another illness. Please call 519 832 5511 or email us to reschedule your appointment.** COVID19 Policies ** Masks are mandatory for anyone over the age of 2 and must be worn at all times, covering the mouth and nose. If you don't have a mask at the time of your appointment, one will be provided for you. If you are unable to wear a mask for any reason, we will need to postpone your visit. Face shields worn without masks cannot be worn in place of a mask. We ask that all patients attend their appointments alone, with the exception of a caregiver bringing someone to their appointment. We ask that children not attend the appointment unless they are the ones being examined. Any extra people brought to the appointment will be asked to wait outside. We ask that upon entering our office, that you immediately wash your hands with soap and water or hand sanitizer. If any of the answers to these screening questions change before your appointment, this screening result is no longer valid and you may need to screen again, wherever necessary. Please give us 24 hours notice if you need to reschedule. Any record created as part of patron screening may only be disclosed as required by law. Thank you for your understanding!Agreement of COVID19 Policies* I have answered NO to the above screening questions AND have read and agree to the above COVID19 Policies.
