Pre-Visit COVID-19 Screening Questionnaire For In-Office Sessions

Following email is sent out to all patients with in-office appointments 3hr before their each appointment as a part of 2 step screening.

Email Title; Pre-Visit COVID-19 Screening Questionnaire For In-Office Sessions

For all in-office sessions, please answer this MANDATORY COVID-19 screening questionnaire honestly prior to your each office visit regardless of your vaccination status. 

 

Failure to do so will result in cancellation of your appointment.

 

Thank you for helping everyone stay safe and healthy!

 

NOTE: 
Screening questions are taken and modified from Toronto Pubic Health, COVID-19 Screening Poster, updated on March 21, 2022.


Original document can be found here.

Mask Wearing Mandate Will Continue At Our Office

Our office is considered to be a health care setting for the purposes of the masking mandate. Thus all patients will be expected to wear a mask at least until June 11, 2022.

 ☐ I agree with mask wearing requirement.

Reference;

https://news.ontario.ca/en/release/1002098/masking-requirements-continue-in-select-indoor-settings

Screening Questions

Q1. Do you or anyone in your household have 1 or more of these new or worsening symptoms today or in the past 5 or 10 days?

 

 ☐ Fever > 37.8C and/or chills = Stay home & self-isolate
 ☐ Cough = Stay home & self-isolate
 ☐ Difficulty breathing= Stay home & self-isolate
 ☐ Decrease or loss of taste/smell= Stay home & self-isolate
 ☐ None of the above

Q2. Do you or anyone in your household have 2 or more of these new or worsening symptoms today or in the last 5 or 10 days?

 ☐ Sore throat = Stay home & self-isolate
 ☐ Headache = Stay home & self-isolate
 ☐ Feeling very tired = Stay home & self-isolate
 ☐ Runny nose/nasal congestion = Stay home & self-isolate
 ☐ Muscle aches/joint pain = Stay home & self-isolate
 ☐ Nausea, vomiting or diarrhea = Stay home & self-isolate
 ☐ None of the above

Q3. Have you or anyone in the household had a positive COVID-19 test in the last 5 or 10 days, or been told to stay home and self-isolate?

 ☐ YES = Stay home & self-isolate
 ☐ NO

Q4. In the last 14 days, have you travelled outside of Canada?

☐ YES = Refer to the federal quarantine travel rules (link below)
☐ NO
 

COVID-19 Travel: Checklists for requirements and exemptions, Government of Canada.
https://travel.gc.ca/travel-covid/travel-restrictions/exemptions

Q5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? (PPE = mask/face covering, goggles, safety glasses, face shield etc.)

 ☐ YES: Your appointment will be cancelled
 ☐ NO
 

Examples of "close contact" are: 

  1. being in the same room or workspace for over 15 minutes (without wearing personal protective equipment )

  2. speaking with someone less than 2 metres away for over 15 minutes (without wearing personal protective equipment ), and

  3. living in the same home.

Screening Results

 ☐ Response to ALL of the screening questions is NO : You may come to your appointment.
 ☐ Response to ANY of the screening questions is YES : Your appointment will be cancelled and rescheduled for a later date. You may and encouraged to continue your care via virtual appointment(s).

Screening questions taken and modified from Toronto Public Health, COVID-19 Screening Poster.

https://www.toronto.ca/wp-content/uploads/2020/05/95ea-Screening-poster-retail-entrance-TPH.pdf?fbclid=IwAR2yVnIeyPb9dTqt9vnM8Te_PH6xKU5C4cZDOyXIf3O-oaGlDxxXHyjXqaQ

Thank you for taking the time to complete the pre-visit screening.

Please remember to come with a mask (disposable or reusable) - regardless of your vaccination status.

You don't have one?
Don't worry, you may purchase a disposable mask at $2 at the door.

We don'y have a waiting area at our office. Please arrive no earlier than 5 minutes from your appointment - so that our clients won't pass each other, and we'll have enough time for a thorough cleaning before your arrival.

Please also know that, regardless of the screening results, you may or may not be accepted for in-office session depending on other factors that are not asked on the screening questions if it appears that risk of in-office treatments outweighs the benefits based on the clinical judgement.

 

Thank you for your understanding.