Covid-19 Intake (Must be completed 24 hours before appointment)

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Email

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor's Name

Doctor's Phone

Doctor's Address

Changes to your medical history since initial intake?

Willing to sanitise hands when entering and leaving clinic

Have you taken precautions to limit exposure

Have you been tested for COVID?

Have you had the antibody test?

Have you been vaccinated?

Fever Over 100.4 degrees

New Onset of Cough

Sore Throat

Decrease or sudden loss of taste and smell

Have you had a new onset of muscle aches and pain since the emergence of the virus?

Nasal or sinus congestion

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?

Recent international air travel

Are you considered high risk?

Spend time around anyone that is high risk

I agree to wear a clean disposable or reusable mask

Do you consent to the consultation, assessment and treatment by the therapist?