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Appointment Pre-Screening

Name*

Email Address*

Date of Appointment *

1. Do you have any of the following symptoms?:

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of smell or taste

Chills

Headaches

Unexplained fatigue/malaise/muscle aches (myalgias)/lethargy

Nausea/vomiting/diarrhea/abdominal pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion (not including allergy symptoms), hoarse voice

2. Has a Doctor, Healthcare Provider, or Public Health Unit told you that you should currently be isolating or staying at home?

3. Have you come into close contact with anyone with a respiratory illness or a confirmed case of COVID 19 within the last 10 days?

4. Are you or someone that you live with awaiting the results of a COVID-19 test?

5. Are you 70 years of age or older?

6. If you are 70 years of age or older, are you experiencing any of the following symptoms?

Delirium

Unexplained or increased number of falls

Acute functional decline

Worsening of chronic conditions

Thanks for submitting!

This checklist provides basic information only and contains recommendations for COVID-19 screening. The screening result is not equivalent to a confirmed diagnosis of COVID-19.

Please fill the following form before your appointment at the Pelham Chiropractic & Wellness Centre in St. Catharines:

If the response to ALL of the screening questions is NO COVID Screen Negative
If the response to ANY of the screening questions is YES COVID Screen Positive

If you answer ‘yes’ to any of these questions (COVID Screen Positive), please call us at 905-988-4357 to reschedule your appointment. 

You are also advised to:

Not attend Pelham Chiropractic & Wellness Centre in person for at least 14 days

Complete the Ontario Government Self Assessment

Contact an appropriate authority such as your family physician, Local Medical Officer of Health (Toll-Free 1-888-505-6074 ) or Telehealth Ontario (Toll-Free 1-866-797-0000 ).

COVID Screen NEGATIVE can be seen at our clinic if they meet the criteria. Call us at 905-988-4357 .

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