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Covid Questionnaire

Full Name *

Date of Service *

Do you have fever above 100.4 F *

Yes

Are you experiencing any of the following symptoms

A cough *

Yes

Shortness of breath *

Yes

Loss of taste of smell *

Yes

Any flu like symptoms such as upset stomach, headache, fatigue or pains *

Yes

Have you been in contact with someone who has tested positive for Covid-19 in the last 14 days *

Yes

If yes, what was the date. You cannot be seen until 14 days after that date.

Have you been tested for Covid-19 in last 14 days *

Yes

What is the result of the testing *

+Ve : You must come back 14 days after free of symptoms.

-Ve

Waiting : You must come back after results are back

Have you travelled anywhere during the last 14 days? *

Yes

If Yes, you have to be in quarantine for 14 days before you can come to your appointment

Are you over 60? *

Yes

Do you have any heart disease, lung disease, kidney disease, diabetes or any other auto immune disease? *

Yes

If Yes, Please List

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CORONAVIRUS HEALTH UPDATE
We are now open for all appointments and accepting appointments for new and existing patients. We have implemented additional infection control guidelines in addition to our already stringent OSHA & CDC requirements. Please do not hesitate to call us if you have any questions or concerns. Thank you.