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Online COVID 19 Screening Form
COVID 19 Screening Form
1. Do you have a new onset or worsening of any of the following symptoms? a) fever / chills, b) cough, c) sore throat / hoarse voice, d) shortness of breath, e) loss of taste or smell, f) vomiting or diarrhea for more than 24 hours
2. Do you have a new onset, or worsening, of any TWO of the following symptoms? a) Runny nose, b) Muscle aches, c) Fatigue, d) Conjunctivitis (pink eye), e) Headache, f) Skin rash of unknown cause, g) Nausea or loss of appetite, h) Poor feeding (if an infant)
3. Have you, or a member of your household, been in close contact (within 2 metres / 6 feet for more than 10 minutes total over 24 hours) in the last 14 days with a confirmed COVID-19 case?
4. Have you been exposed to COVID-19 in a work or public setting in the last 14 days (e.g. a setting that has been identified by public health as a risk for acquiring COVID-19, such as on a flight, in a workplace or community with a cluster of cases, or at an event)?
5. Are you, or a member of your household, waiting for COVID-19 testing results?
6. In the last 14 days have you or anyone living in your household travelled outside of Manitoba?
If you answered YES to question 6., please answer question 7. 7. Are you or your household traveler exempt from requirements to self-isolate (quarantine)? The most common self-isolation exemption is for individuals who have completed a full series of COVID-19 vaccine and two weeks have passed at the time of their arrival since their last dose. This exemption includes children who are not eligible for the vaccine based on age, if all individuals they travelled with are fully immunized (New June 12, 2021)
I hereby confirm that the above information is correct to my knowledge. This confirmation and consent will apply to today and all visits going forward. I agree that should any of my answers to the above questions change before a subsequent office visit, I will cancel my appointment and refrain from being in the office until directed by Health Links – Info Santé or the Shared Health MB Online Screening Tool.
I agree with the statements above and consent to receive chiropractic care in the office
I understand that while governmental guidelines on sanitization and distancing are being followed in the practice, it is not guaranteed that there has not been a potentially infected person within the office where exposure could occur.
I agree with the statement above and consent to receive chiropractic care in the office
This field is for validation purposes and should be left unchanged.