COVID-19 Self Assessment Tool

Name *

First

Last

Do you have any of the following - click all that apply *

Fever greater than 38°C or 100.4°F
Cough
Headache
Muscle and/or joint aches and pains
Sore throat
Chills
Runny nose
Nasal Congestion
Conjunctivitis
Dizziness
Fatigue
Nausea/vomiting
Diarrhea
Loss of appetite (difficulty feeding for children)
Loss of sense of taste or smell
Shortness of breath
Difficulty breathing
None of the above

Please choose all that apply

Were you exposed to someone who is under investigation for COVID-19 or has been confirmed as having COVID-19 within the last 14 days? *

Yes
No

In the past 14 days have you returned from or been exposed to someone who has returned from any out of province travel? *

Yes
No

Please note, answering YES does not prevent you from attending your scheduled appointment.

Have you traveled to or visited any area of Saskatchewan that Public Health has deemed an outbreak area or has an elevated risk for acquiring Covid-19 within the past 14 days? *

Yes
No

Please note, answering YES does not prevent you from attending your scheduled appointment. **Here is the link for the current SK Health Outbreak List in Saskatchewan https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/latest-updates/covid-19-active-outbreaks#south-outbreaks

CORONAVIRUS (COVID-19): The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and COVID-19 is extremely contagious. The Speech Language Network has put in place preventative measures to reduce the spread of COVID-19; however, The Speech Language Network cannot guarantee that you or your child will not become infected with COVID-19. Furthermore, the client/family and therapist will collaboratively decide best PPE implementation for the client’s specific needs. By checking yes, you acknowledge you are aware of the risks, dangers and hazards, and that you are participating in therapy services at the Speech Language Network. Further details of enhanced protocols and guidelines to ensure the safety of our staff and can be found at www.thesln.com/clinic-policies .

Do you acknowledge you are aware of the risks, dangers and hazards, and that you are participating in therapy services at the Speech Language Network? *

Yes
No

Please solve to Submit this form. Thank You. *

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