Covid-19 Screening 1. Please select your Occupational Therapist / Case Manager / Speech Therapist ---Aimee McDevittAlina CarrancoAmanda AbbottAndrea DreifeldsAnnette CampbellAshley McPhailBrittony OslerCaitlyn McKinleyCatherine BrayChelsea GagnonChristine AndrusChristine KarelsenColin MooreDonna MathesonEmma WintersErin HawkinsErin RiversEva CoegoFiona Smith BradleyHeather KatsabanisHeather LuneburgJaelle BrienJanice BlackwellJessica SkuceJoan Jasmin CameronJill Stolins-MalloryKaitlyn WalshKate BerryKatelyn BridgeKathy NezanKaty AtkinsonLeanna HaidarLisa Abbott MooreLois DetlefsenMaggie KinneyMary Oldford-McIntoshRhonda JohnstonSandeep KaushikSara UbbensShannon McGrathStephanie Caissie ScoularModern OT Administration First Name (required) Last Name (required) Your Email (required) 2. Have you travelled outside of Canada in the past 14 days? YesNo 3. Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? YesNo 4. Do you have any of the following symptoms? Fever YesNo New onset of cough YesNo Worsening chronic cough YesNo Shortness of breath YesNo Difficulty breathing YesNo Sore throat YesNo Difficulty swallowing YesNo Decrease or loss of sense of taste or smell YesNo Chills YesNo Headaches YesNo Unexplained fatigue-malaise-muscle aches - myalgias YesNo Nausea-vomiting, diarrhea, abdominal pain YesNo Pink eye - conjunctivitis YesNo Runny nose or nasal congestion without other known cause YesNo 5. If you are 70 years of age or older, are you experiencing any of the following symptoms? Delirium YesNo Unexplained or increased number of falls YesNo Acute functional decline YesNo Worsening of chronic conditions YesNo COVID-19 Screening Results If response to ALL of the screening questions is NO: COVID Screen Negative If response to ANY of the screening questions is YES: COVID Screen Positive Please complete and submit this form prior to your appointment. If you require assistance or have questions about this form, please contact Modern OT at 613-792-3461 Submit
