Covid Consent Form

Willing to wash hands before entering clinic

Willing to wash hands before leaving clinic

Willing to wear face mask in the clinic

Agree to wear face mask during treatment

Have you taken precautions to limit exposure

Have you been tested for COVID?

Have you had the antibody test?

Fever Over 100.4 degrees

Fever Over 38 degrees

Headaches

What is your Temperature?

New Onset of Cough

Worsening Chronic Cough

Sore Throat

Difficulty Swallowing

Shortness of Breath

Difficulty Breathing

Persistent Pain in Chest

Decrease or sudden loss of taste and smell

Have you had a new onset of muscle aches and pain since the emergence of the virus?

Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)

Fatigue

Chills

Pink eye (conjunctivitis)

Nasal or sinus congestion

Runny nose/nasal congestion without other known cause

Nausea

Vomiting

Diarrhea

Abdominal Pain

Sudden onset body aches

New rash or other skin changes

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?

Regular cardio exercise

Can you exercise to get your heart rate up without any problem?

Can you exercise to get your respiratory rate up without any problem?

Contact with someone with COVID

Had close contact with a confirmed case of COVID-19 without wearing PPE

Contact with someone who was in contact with COVID

Contact with anyone with acute respiratory Illness

Recent domestic air travel

Recent international air travel

Recent travel to area with high infection rates

Recent travel outside your province within the past 14 days

Did you travel outside of Canada in the past 14 days?

Been in group where social distancing not observed

Are you considered high risk?

Spend time around anyone that is high risk

If over 70, unexplained or increase number of falls?

If over 70, acute functional decline?

If over 70, worsening of chronic conditions?

If over 70, symptoms of delirium?