• COVID-19 Health Screening Form

    COVID-19 Health Screening Form

    If you have been exposed to a communicable disease, you may spread the disease to the acupuncturists, office staff, or other patients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

  • Do you, your child, or anyone you have recently been in contact with have any of the following symptoms?

  • A Fever (defined as above 100.4° F degrees)*
  • Cough?*
  • Shortness of breath or difficulty breathing?*
  • Sore throat?*
  • Persistent pain, pressure, or tightness in chest?*
  • New loss of taste or smell?*
  • Select yes for this response
  • Have you, your immediate family, or anyone you've recently come in contact with traveled out of town within the past 90 days?*

  • Many of our patients, including one of our providers, are elderly and/or have health conditions that put them at high risk.  Your honesty is greatly appreciated during this difficult time for all.

  • Have you ever been tested positive for COVID-19?*
  • When did you last receive a negative test result? Enter negative test result date in the third box. We appreciate your honesty.*

  • Have you, your immediate household, or anyone you've recently come in contact with test positive for or been diagnosed with Covid-19 or other communicable disease?*
  • Does your job, or if you are a student, require you to be in contact with 6+ people (clients, colleagues, etc) at any given time?*
  • Have you recently attended any event or gathering with more than 6 people who do not share the same residence as yourself?*
  • If yes, please provide approximate initial date of illness.
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: