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1. Do you/have you had a fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing within the past 14 days?
2. Have you travelled outside of Canada or Ontario within the past 14 days?
3. Have you had close contact with anyone with acute respiratory illness or anyone who has travelled outside of Canada or Ontario within the past 14 days?
4. Have you been confirmed positive for Covid-19 or have you been in close contact with anyone who has tested positive for Covid-19?
5. Are you currently waiting for Covid-19 test results?
6. Are you immuno-compromised?
7. Do you have 2 or more of the following symptoms?
8. Do you have any underlying health issues? Ie; diabetes, heart disease, high blood pressure, kidney disease, asthma, COPD (chronic obstructive pulmonary disease)
9. Have you had any recent surgeries or injuries?
10. Have you experienced any acute functional declines, falls, worsening of current or chronic conditions?
11. Do you work in a healthcare environment and/or are exposed to people who are ill?
Covid-19 Pre-Screening Questionnaire Informed Consent Form
BEFORE YOUR APPOINTMENT
There will be some changes to the way appointments are scheduled and some new procedures for arriving to your appointment to keep you safe.
DURING YOUR APPOINTMENT
Although protocol and procedure has changed, you can expect the same standard of treatment and care as before.
BEHIND THE SCENES…
Your safety and wellbeing is most important to me. These are difficult and unprecedented times. I am following guidelines set under the Regulated Health Professions Act (RHPA), the Ontario’s Chief Medical Officer of Health (CMOH) and the Ontario Ministry of Health. These are the precautions I am taking;
As you may or may not know, my son, Noah, is immuno-compromised due to the medication he takes for Crohn’s disease and Chronic Kidney Failure. Due to this reason, my bathroom facilities are completely off limits to patients..no exceptions. I apologise for this inconvenience but it is necessary. Please keep this in mind before your appointment and thank you for your understanding.
I want to thank each and every one of you for your patience and understanding during this confusing and unpredictable time. I hope to get back to a normal that allows me to provide treatment regularly and consistently. Please know I am bound to follow the guidelines set out by our Provincial Government and by my Professional Association.
I look forward to seeing you soon.
Karyn (Tizzard) M.OMSc
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