Health Screening

This health assessment form contains questions sourced from the BC Ministry of Health COVID-19 self assessment tool. NOTE: This form must be filled out in order for us to proceed with your treatment. We appreciate your time and honesty in answering these health screening questions. Measures like this allow us to continue providing a safe space for self-care for you, our clients, and staff.

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Health Screening

Name*
Are you experiencing any of the following:*
Are you experiencing any of the following:*
Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? (NOTE: please do not indicate yes to symptoms you are confident are due to seasonal allergies.) 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
Did you provide care or have close contact with a person with confirmed COVID-19?*