COVID 19 - Screening

First Name

Last Name

Email

Fever / Headache / Difficulty Swallowing / Sore Throat / New Cough / Cough Worsening / Difficulty Breathing / Persistent Chest Pain / Loss of Taste or Smell / Muscle Aches / Fatigue / Chills.

Yes

No

Pink Eye / Nasal or Sinus Congestion / Nausea / Diarrhea / Vomiting / Pink Eye / Nasal or Sinus Congestion / Abdominal Pain / Sudden Onset of Body Pain / New Rash or Other Skin Changes.

Yes

No

If a child, are they experiencing purple markings on fingers and toes?

Yes

No

Have you had any changes to your medical history since the initial intake?

Yes

No

Are your willing to wash hands before entering clinic?

Yes

No

Are you willing to wear face mask in the clinic and during treatment??

Yes

No

Have you tested positive for COVID-19 in the last month?

Yes

No

Have you been in contact with anyone with COVID-19 or had close contact with a confirmed case of COVID-19?

Yes

No

Have you been around anyone with cold-like symptoms?

Yes

No

Have you travelled recently outside the country or been on an airplane?

Yes

No