Assessment form







Please contact directly each consultant listed below

TriCities Therapy Clinic Screening Checklist

Section 1 Have you or your child(ren) been diagnosed with COVID-19 or have you been tested and are awaiting to hear the results?
YesNo

Have you or your child(ren) been told by public health that you may have been exposed to COVID-19
YesNo

Have you or your child(ren) traveled outside of BC in the past 14 days
YesNo

Have you or your close family been in contact with someone who has tested positive for COVID-19, is suspected to have COVID-19 or who has a fever, cough or shortness of breath that started within 14 days of travel outside of Canada (including the United States of America)?
YesNo

*** If parent/child has answered "Yes" to any questions in Section 1, treatment should be postponed for at least 2 weeks from the date of this questionnaire and a new questionnaire be conducted at that time.

Section 2
Do you have a fever of 38° C or above?
YesNo

Do you have a new cough or a worsening chronic cough? Do you have a sore throat? Do you have a runny nose?
YesNo

Do you have a headache?
YesNo

A new onset of muscle pain?
YesNo

Diarrhea/Nausea/Vomiting?
YesNo

A loss of taste
YesNo

A loss of smell?
YesNo

In children, purple markings on fingers and / or toes?
YesNo

Do you understand that exposure to COVID 19 is a risk we are taking, so do you wish to proceed with the scheduled appointment?
YesNo

*** If you or your child(ren) answered YES and are experiencing any of the above signs or symptoms or refuse to answer, they cannot enter the clinic and will need to self-isolate for a period of 14 days; recommend they call 811 or see / contact their physician.

*** Individuals that pass the screening (answered NO to all questions) will have their temperature taken outside the front door and if under 38 ° C, will be allowed to enter the clinic.

If a child begins to experience any symptoms while in the clinic, the child will be immediately requested to go home and environmental cleaning of the space the child was in will be conducted once the child has been picked up.

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