Pre-appointment COVID-19 Self Assessment

It is a regulatory requirement that prior to every appointment you provide me with answers to the 

COVID-19 self assessment. You will need to provide your answers on arrival to EVERY appointment.

If you do answer yes to any of the listed questions call in to determine if your appointment needs to be rescheduled. 

Your co-operation will make everyone safer and provide some efficiency in clinic procedures.



1. Are you experiencing any of the following :

  • Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)

  • Severe chest pain

  • Having a very hard time waking up

  • Feeling confused

  • Losing consciousness


2. Are you experiencing any of the following (beyond your normal):

  • Mild to moderate shortness of breath

  • Inability to lie down because of difficulty breathing

  • Chronic health conditions that you are having difficulty managing because of difficulty breathing


3. Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones ?

Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.


4. Have you travelled outside of British Columbia within the last 14 days?


5. Did you provide care or have close contact with a person with confirmed COVID-19?

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