Self-Assessment for COVID-19
Semiahmoo Speech Services Inc.

This questionnaire must be completed prior to the first visit to Semiahmoo Speech Services Inc. It must be electronically signed by the adult/parent before the first session. It needs to be completed one time only; however this assessment will be referred to before each session as the clinician has the right to ask you any of the questions below prior to beginning a session.

You need to complete this assessment for yourself and on behalf of someone else (if your child is attending the clinic).

Older people and people with a weakened immune system or underlying medical conditions are considered at higher risk of severe disease are recommended not to attend in-office sessions.

Note that this self-assessment tool is intended for COVID-19 only. Your symptoms may not be related to COVID-19 and could require you to seek medical attention. If you are uncertain and/or feel very sick, contact your family doctor/nurse practitioner or call 8-1-1.

  • If you are experiencing any of the following symptoms, do not come to the clinic and do not sign this form:
    • Fever
    • Chills
    • Cough
    • Shortness of breath
    • Sore throat
    • Painful swallowing
    • Stuffy or runny nose
    • Loss of sense of smell
    • Headach
    • Muscle aches
    • Fatigue
    • Loss of apetitie
    • 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
    • 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
    If you have travelled to any countries outside Canada (including the United States) within the last 14 days, do not come to the clinic
  • Enter your full name below to confirm:
  • PART B INFORMED CONSENT Please read and make note of Semiahmoo Speech Services Informed Consent In the current environment of COVID-19 risk, informed consent requires that the client be informed and understands that: Any speech and language therapy treatment involves some risk of COVID-19 transmission; The therapist is following protocol to help reduce or mitigate risk where possible, but that risk cannot be reduced to zero; The client consents to the treatment despite some risk; And the therapist will document the client’s consent in advance of the onset of treatment. Your informed consent will be collected when you fill out the COVID-19 assessment.
  • Enter your full name below to consent: