CONFIDENTAL CLIENT COVID-19 PRE-SCREENING
•PLEASE FILL OUT THIS FORM AND RETURN IT TO YOUR THERAPIST NOT LESS THAN 24 HOURS BEFORE YOUR APPOINTMENT. IF YOUR CONDITION CHANGES FROM THE TIME THAT YOU SUBMIT THIS FORM TO YOUR THERAPIST AND BEFORE YOUR APPOINTMENT TIME, PLEASE RE-EVALUATE YOURSELF BEFORE ATTENDING THE APPOINTMENT.
Are you experiencing any of the following?•severe difficulty breathing (e.g., struggling for each breath, speaking in singlewords)•severe chestpain•having a very hard time waking up•feelingconfused•lost consciousness
Are you experiencing any of the following?•shortness of breath atrest•inability to lie down because of difficulty breathing•chronic health conditions that you are having difficulty managing because of your current respiratory illness
Do you have any of the following?•fever•new onset of cough or worsening of chronic cough•new or worsening shortness of breath•new or worsening difficulty breathing•sore throat•runny nose
Do you have any of the following?•chills•painful swallowing •stuffy nose•head ache•muscle or joint ache•feeling unwell, fatigue or severe exhaustion•nausea, vomiting, diarrhea or unexplained loss of appetite•loss of sense of smell ortaste•conjunctivitis (pinkeye)
If you answered yes to any of these questions you are absolutely contraindicated for massage or manual osteopathic treatment. You must call to cancel your appointment. You may need to self-isolate. It is recommended that you immediately contact your local health authority and follow their instructions.
You have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.
•Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.•Practice good hygiene: wash hands often, cover coughs and sneezes, and avoid touching your face.•Monitor for COVID-19 symptoms: fever, cough, shortness of breath, sore throat or runny nose.•If you do develop any COVID-19 symptoms, stay home and take this self-assessment again.
In order to protect yourself, your therapist, health, and other, honest disclosure is essential.
Due to the COVID-19 pandemic, we are taking extra precautions with the intake of each client. Please answer these questions truthfully so we may continue to do our best to stop the spread.
Primary symptoms of COVID-19 may include:•new cough or a chronic cough that is worsening•fever•new or worsening shortness of breath ordifficulty breathing•sore throat•runny nose
Secondary symptoms of COVID-19 may include:•stuffy nose•painful swallowing•headache•chills•muscle or joint pain•gastrointestinal symptoms•loss of sense of smell or taste•conjunctivitis (pink eye)
•I understand the above symptoms and affirm that I, as well as all members of my household, do not currently have nor have experienced COVID-19 symptoms within the last 14 days.•I affirm that I, as well as all members of my household, have not been diagnosed with COVID-19 within the last 14 days•I affirm that, to my knowledge, in the last 14 days I have not been in contact with anyone who has been diagnosed with COVID-19•I affirm that if I travelled outside of Canada in the last month, I isolated in my home for 14 days upon my return.•I understand that, because massage therapy and other natural health practices involvemaintaining prolonged and close physical contact, there may be an elevated risk of diseasetransmission, including COVID-19 •I understand that this business and my NHPC practitioner (identified above) cannot be heldliable should I experience exposure to the virus or any other contagion as a result of myproviding misinformation on this form.
By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage therapy and bodywork
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