COVID Screening Questionnaire Name(Required) First Last Do you have new or worsening respiratory symptoms?(Required) Yes No Do you have any of the following symptoms?Sense of taste(Required) Yes No Muscle aches(Required) Yes No Fatigue(Required) Yes No Headache(Required) Yes No Diarrhea may be present in addition to respiratory symptoms(Required) Yes No Nausea(Required) Yes No Vomiting(Required) Yes No Have you been in contact in the last 14 days with someone confirmed to have COVID-19?(Required) Yes No In the last 14 days have you attended a current place of interest?(Required) Yes No Are you required to self-isolate or waiting for COVID test results?(Required) Yes No Have you travelled internationally and returned in the last 14 days either via MIQ facility or home/self-isolation?(Required) Yes No Have you had direct contact with someone who has travelled overseas? in the last 14 days?(Required) Yes No Is there any reason why you cannot wear a face mask as mandated by the Ministry of Health?(Required) Yes No Please state reason hereConsent I confirm the information provided is true and accurateThe information that I have provided is accurate and true. Services at Omkoroa Physiotherapy may be declined due to being in close contact, been at a location of interest or showing symptoms of COVID-19.
