JINSONG TCM & ACUPUNCTURE  WELLNESS CLINIC

JINSONG TCM & ACUPUNCTURE WELLNESS CLINIC COVID-19 

Screen Questions and Consent Form

Printed Name: _____________________________Date: _____________________

● I understand the novel coronavirus causes the disease known as COVID-19.

● I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

● I confirm that I read the following questions and all the answers are "NO"

Ontario Ministry of Health COVID-19 Patient Screening Questions

Q1: Did you have close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days?

Q2: Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Q3: 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 taste or smell

.Chills

.Headaches

.Unexplained fatigue/malaise/muscle aches (myalgias)

.Nausea/vomiting, diarrhea, abdominal pain

.Pink eye (conjunctivitis)

.Runny nose/nasal congestion without other known cause

Q4: 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, or worsening of chronic conditions? 

● I confirm I am not currently positive for the novel coronavirus

● I confirm that I am not waiting for test results of a laboratory test for the novel coronavirus

● I verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus, or train in the past 14 days.

● I understand that any travel from any country outside Canada, including travel by car, air, bus, or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada.

● I understand that Ontario Health Services has asked individuals to maintain social distancing of at least 2 meters (6 feet) and it is not possible to maintain this distance during receive Chinese Medicine, acupuncture or massage treatment, there may be an elevated risk of disease transmission, including COVID-19.

● I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Ontario Health Services, the Communicable Disease Control or any other governmental health agency.

  I verify the information I have provided on this form is truthful and accurate. I acknowledge that I am aware of the risks involved and give consent to have Acupuncture, Chinese Medicine or Massage Therapy Treatment from JINSONG TCM & ACUPUNCTURE WELLNESS CLINIC.

________________________________________

SIGNATURE OF CLIENT