COVID-19 SCREENING QUESTIONS
For the safety of you and I, please complete this form out 24 hours prior to your treatment (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
In the past 7 days, I have experienced...
Yes
No
Have you tested positive for COVID-19 in the last 7 days?
1
2
Are you waiting for a COVID-19 test or the results?
3
4
Do you have a high temperature or fever?
5
6
Do you have a new or continuous cough?
7
8
Do you have loss or change in.........
9
10
Sense?
11
12
Smell?
13
14
Taste?
15
16
Do you or anyone in your household have symptoms of COVD-19?
17
18
Have you been in contact with anyone in the last 14 days who is experiencing COVID-19 symptoms?
19
20
Signature
Submit
Should be Empty: