Covid-19 Screening 1. Please select your Occupational Therapist / Case Manager, then fill in your name and contact —Please choose an option—Alina CarrancoAmanda AbbottAndrea DreifeldsAnnette CampbellBrittony OslerCaitlyn McKinleyCatherine BrayChanelle PattersonChelsea GagnonChristina Della CroceChristine AndrusChristine GirardChristine KarelsenColin MooreDonna MathesonEmily SaucierEmma WintersErin RiversEva CoegoFiona Smith BradleyHeather KatsabanisHeather LuneburgJaelle BrienJanice BlackwellJessica SkuceJoan CameronJill Stolins-MalloryKate BerryKatelyn BridgeKathleen LegassicKathy NezanKatie GardinerLeanna HaidarLois DetlefsenMaggie KinneyMary Oldford-McIntoshRaina CoppicusRenée KielichRhonda JohnstonSandeep KaushikSara UbbensSarah Murphy BurkeShannon McGrathStephanie Caissie ScoularVéronique LortieModern OT Administrationolivia@modernot.cateke@modernot.ca Your First Name (required) Your Last Name (required) Your Email (required) 2. Do you have ONE OR MORE of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions, if you are uncertain, please ask for guidance. Fever greater than 37.8 and/or chills Difficulty breathing or shortness of breath Cough Decrease or loss of smell or taste YesNo 3. Do you have TWO OR MORE of the following new or worsening symptoms? Symptoms should not be related to known causes or conditions, if you are uncertain, please ask for guidance. Extreme tiredness Muscle aches or joint pain Nausea, vomiting, and/or diarrhea Sore throat Runny nose or stuffy nose Headache YesNo 4. Have you tested positive for COVID-19 in the last 10 days? YesNo *If your answer is YES to 4, and this was the first positive test, please contact Modern OT to reschedule or make alternate arrangements. *If your answer is YES to 4, but 10 days have passed since you first tested positive, and your responses to 2 and 3 are NO, we can proceed with the appointment. Please wear a well-fitted mask to your appointment. COVID-19 Screening Results If response to ALL of the screening questions is NO: COVID Screen Negative. Your appointment will continue as scheduled. If response to any of the screening questions 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
