COVID-19 Questionnaire

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This client disclosure form seeks information from you that we must consider before choosing to have an in-person session in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider shifting to an outdoor, phone or Zoom session.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus

Email *

Have you been in contact with someone who has tested positive for COVID-19? *

Yes

Have you tested positive for COVID-19? *

Yes

If so, how long ago?

Have you experience any of these flu like symptoms: Fever, trouble breathing or shortness of breath, cough, runny nose, sore throat, chills, muscle pain, lose or reduction to sense of smell, upset stomach, headache or fatigue *

Yes

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. I acknowledge that the answers I have provided above are true and accurate. *

Yes, I fully understand & my answers are true & accurate.

Full Name & Date *

Send me a copy of my responses.

Submit

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