top of page
Client Screening Questionnaire
Your cooperation and compliance will help to ensure your health and safety as well as the safety of others. Until further notice, please fill out a health questionnaire
24 hours prior to
. Be sure that the information you provide is accurate and complete.
All accompanying Aide’s must also complete this form for
Date of Appointment
1. Have you traveled outside the US in the past 30 days?
If Yes, Where?
2. Have you traveled to a US city/state with reported cases of Coronavirus in the past 30 days?
If Yes, Where?
3. Have you been in personal contact with a person infected with Coronavirus or who has traveled to an area with widespread and transmission of COVID19 in the past 30 days?
4. Have you tested positive for COVID-19?
5. Do you live with OR take care of anyone who has tested positive for COVID-19?
6. Have you tested for COVID-19 and are waiting for results?
7. In the past 14 days, have you experienced any of the following? (check all that apply)
Fever (99.5 and above)
Unexplained body aches or pain
Shortness of Breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores of soles of feet
Non-allergy related runny nose
None of the Above
*Please sign within box. If you are having issues, please fill out this form via computer.*
Your Signature (use mouse or finger to sign)
Thank you for submitting!
RETUrn to client page
LEARN MORE: KEYWORDS AND DETAILS
bottom of page