Patient Screening Form | Royal York Massage Therapy

Patient name:*

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Patient

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SCREENING QUESTIONS

Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days?*

Yes

No

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?*

Yes

No

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 or 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/nasal congestion without other known cause

Yes

No

Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?*

Yes

No

I verify the information I have provided on this form is truthful and complete.

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