COVID-19 Pre-Screening Form

  • Signs of a fever:
    • in adults: 38°C (100.4°F) and above (oral temperature),
    • in older adults: 37.8°C (100°F) and above (oral temperature),
    • in children: 38°C (100.4°F) and above
    • or 1.1°C above the person's usual value
  • • severe difficulty breathing (e.g., struggling for each breath, speaking in single words)
    • severe chest pain
    • having a very hard time waking up
    • feeling confused
    • loss of consciousness
    • shortness of breath at rest
    • inability to lie down because of difficulty breathing
    • chronic health conditions that you are having difficulty managing because of your current respiratory illness
  • • fever
    • new onset of cough or worsening of chronic cough
    • new or worsening shortness of breath
    • new or worsening difficulty breathing
    • sore throat
    • runny nose
    • chills
    • painful swallowing
    • stuffy nose
    • headache
    • muscle or joint ache
    • feeling unwell, fatigue or severe exhaustion
    • nausea, vomiting, diarrhea or unexplained loss of appetite
    • loss of sense of smell or taste
    • conjunctivitis (pink eye)
  • If you answered yes to any of these questions you are absolutely contraindicated for massage or manual osteopathic treatment. You must call to cancel your appointment. You may need to self-isolate. It is recommended that you immediately contact your local health authority and follow their instructions.
    You have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.
    • Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.
    • Practice good hygiene: wash hands often, cover coughs and sneezes, and avoid touching your face.
    • Monitor for COVID-19 symptoms: fever, cough, shortness of breath, sore throat or runny nose.
    • If you do develop any COVID-19 symptoms, stay home and take this self-assessment again.

    Confidential History In order to protect yourself, your therapist, health, and other, honest disclosure is essential.