Patient's Name Date Phone Number Time


Please check the answer to each yes or no question, and click on the "Send Form" button to submit the information.

Patient's Self-Declaration

1. Have you been in close contact with someone who is sick or has confirmed COVID-19 in the past 14 days?
Yes
No

2. Have you returned from travel outside Canada in the past 14 days?
Yes
No

3. Have you been in close contact with anyone who has traveled within the last 14 days Outside Canada?
Yes
No

4. Do you have Fever?
Yes
No

5. Do you have Cough?
Yes
No

6. Do you have Shortness of breath?
Yes
No

7. Do you have Sore throat?
Yes
No

8. Do you have Runny Nose?
Yes
No

9. Do you feel unwell?
Yes
No

If you answered YES to any of these questions,
go home & self-isolate right away. Contact your family doctor or health care provider






   
If you need more information about infection control and would like to read more You can Click here

CherrytreePhysiotherapy.com

Precautionary Measures Against Covid Variants
The safety of our patients, families and visitors remain our overriding priority. As the corona
virus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, Our Clinic is
monitoring the situation closely and will be guided by current recommendations from the
Centers for Disease Control and Prevention. To prevent the spread of COVID-19 and reduce
the potential risk of exposure to our patients/ visitors, we are conducting a simple screening
questionnaire. Your participation is important to help us take precautionary measures to
protect you and everyone in this facility. Thank you for your time.
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