Covid-19 Screening French Screening Form 1. Please select your Occupational Therapist / Case Manager / Speech Therapist, then fill in your name and contact ---Alina CarrancoAmanda AbbottAndrea DreifeldsAnnette CampbellBrittony OslerCaitlyn McKinleyCatherine BrayChanelle PattersonChelsea GagnonChristina Della CroceChristine AndrusChristine GirardChristine KarelsenClaire PerreaultColin MooreDaphné TrudelDonna MathesonEmily SaucierEmma WintersErin HawkinsErin RiversEva CoegoFiona Smith BradleyHeather KatsabanisHeather LuneburgJaelle BrienJanice BlackwellJessica SkuceJoan CameronJill Stolins-MalloryKate BerryKatelyn BridgeKathy NezanLeanna HaidarLisa Abbott MooreLois DetlefsenMaggie KinneyMary Oldford-McIntoshRenée KielichRhonda JohnstonSandeep KaushikSara UbbensShannon McGrathStephanie Caissie ScoularVéronique LortieModern OT Administration Your First Name (required) Your Last Name (required) Your Email (required) 2. Are you fully vaccinated against COVID-19? YesNo 3. Are you currently experiencing any of these symptoms (not related to other known causes or conditions you already have)? Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher). YesNo Cough or barking cough/croup (Continuous, more than usual, making a whistling noise when breathing). YesNo Shortness of breath (Out of breath, unable to breathe deeply). YesNo Decrease or loss of sense of taste or smell YesNo Muscle aches/joint pain (Unusual, long-lasting). YesNo Extreme tiredness (Unusual, fatigue, lack of energy). YesNo Sore throat (Painful or difficulty swallowing). YesNo Runny or stuffy/congested nose YesNo Headache (New, unusual, long-lasting). YesNo Nausea, vomiting, and/or diarrhea YesNo 4. In the last 10 days, has someone you live with: Been sick with symptoms associated with COVID-19? YesNo and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)? YesNo 5. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? YesNo 6. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you are fully vaccinated, select “No”. YesNo 7. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? If public health has advised you that you do not need to self-isolate, select “No”. YesNo 8. In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No”. YesNo COVID-19 Screening Results If response to ALL of the screening questions (other than 2) is NO: COVID Screen Negative. Your appointment will continue as scheduled. Please continue to follow all public health measures, including masking, maintaining physical distance, and hand hygiene, where applicable. If response to ANY of the screening questions (other than 2) is YES: COVID Screen Positive. Please contact Modern OT prior to your appointment to discuss whether an alternate arrangement needs to be made. 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. Source Submit
