(No more appointments may be booked now that Healthy By Nature is closed.)
COVID-19 Screening Questionnaire
Safety is our number one priority. Thank you for your patience during this challenging time.
1. Do you have current symptoms of COVID-19? These symptoms must be new or not related to a known or pre-existing condition: (Please check off all that apply)
Fever Cough Sore throat Runny nose Nasal or Sinus congestion Shortness of breath Chills Unexplained Fatigue Rash Diarrhea Nausea Vomiting Loss of smell
2. Have you (the patient) travelled internationally within the last 14 days?
Yes No
3. Have you had contact with individual(s) who have a confirmed or presumptive diagnosis of COVID-19?
4. Have you had close contact with anyone who had an acute respiratory illness that started within 14 days?
If you answered YES to any of those questions, we ask that you do not come into the clinic, that you self-isolate, and you may need to call HealthLink (811) for further instructions.
COVID-19 Consent:
I understand that social distancing can not be maintained during treatment and that, while the practitioner is following all of the health and safety guidelines outlined by the Provincial Health Officer and the AAOMT for Osteopathy, the Canadian College of Naturopathic Medicine, the College and association of Acupuncture of Alberta, and that they are taking all reasonable precautions to clean and disinfect the clinic and all the surfaces within the treatment room, there are no guarantees that I will not come into contact with COVID-19.
I Agree
Please sign below to confirm that you have read, understand, and truthfully answered this questionnaire:
Name:
Signed on
Comments are closed.
