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 Ontario Ministry of Health COVID-19 Patient Screening Guidance Document, Version 5.0. August 26, 2021.

 

Original document can be found here.

Background Question

Q1. Did you receive your final (or second) vaccination dose more than 14 days ago?

 

NOTE: This is asked solely for the purpose of prompting the appropriate subsequent screening questions set by the Ministry of Health. No one will be turned away based on their vaccination status itself.

 ☐ YES = Chose "EXEMPT" for Questions 4 & 5
 ☐ NO = Answer all following screening questions
 ☐ I do not wish to disclose my vaccination status = Answer all following screening questions

* A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).

Screening Questions

Q2. Do you have any of the following signs or symptoms?

 ☐ Fever and/or chills
 ☐ New onset of cough or worsening chronic cough
 ☐ Shortness of breath
 ☐ Decrease or loss of sense of taste or smell
 ☐ Adult > 18 years of age: unexplained fatigue / lethargy / malaise / muscle aches (myalgias)
 ☐ Child < 18 years of age: nausea/vomiting, diarrhea
 ☐ None of the above

Q3. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?

 ☐ YES = Your appointment will be cancelled regardless of your vaccination status
 ☐ NO

Q4. Did you travel outside of Canada in the past 14 days? 

 ☐ YES: Your appointment will be cancelled
 ☐ NO
 ☐ EXEMPT: If you answered "YES" to question 1

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
 ☐ EXEMPT: If You answered "YES" to question 1

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 or EXEMPT : You may come to your appointment.
 ☐ Response to ANY of the screening questions is YES : Your appointment will be cancelled.

Screening questions taken and modified from Ontario Ministry of Health COVID-19 Patient Screening Guidance Document, Version 5.0. August 26, 2021

https://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_patient_screening_guidance.pdf?fbclid=IwAR3xUgns2FV1JbOHHS6LQ_W2NVp3l6D4AXamVSGP-w__5eCT7dnmm4wsWrw

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.