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COVID-19 Questionnaire

QUESTION 1

Have you experienced any of the following symptoms in the past 48 hours:

  • fever or chills

  • cough

  • shortness of breath or difficulty breathing

  • fatigue

  • muscle or body aches

  • headache

  • new loss of taste or smell

  • sore throat

  • congestion or runny nose

  • nausea or vomiting

  • diarrhea

#1

QUESTION 2

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:

  • Anyone who is known to have laboratory-confirmed COVID-19? OR

  • Anyone who has any symptoms consistent with COVID-19?

#2

QUESTION 3

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

#3

QUESTION 4

Are you currently waiting on the results of a COVID-19 test?

#4

Thanks for for your commitment to safety!

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COVID-19 & Our Commitment to Patient Safety

 

Major Changes Rehab Centre (MCRC) values the health and safety of our patients. We are committed to taking every precaution and safeguard and continue to closely monitor developments. We understand that the most important factor in the success of your physical therapy is the completion of your treatment, we are taking the risk seriously and wish to assure you of the procedures that we have in place.

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