COVID-19 Screening Survey

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Thank you for helping us keep our office safe! Please complete this survey prior to you in-person acupuncture appointment. If you have any questions, please call us at (415) 925-8600.
Thank you,
Dr. Rossman and Mariel

Name: *

Date of acupuncture appointment:

In the past 14 days, have you had any of the following symptoms? (Select all that apply): *

Fever

Dry Cough

Muscle Aches

Digestive Illness

Sore Throat

None of the above

Required

Have you travelled by air or other public transportation in the last two weeks? *

Yes

If yes, what date did you return?

YYYY

Have you had close exposure to anyone outside your normal household within the last two weeks? *

*Close contact means a meeting or interaction lasting more than 15 minutes with a person who is closer than 6 feet away from you, or physical contact like handshaking, hugging, or kissing.

Yes

If yes, what was the last date of exposure?

YYYY

Do you routinely wear masks, keep social distance and wash your hands frequently if outside your home? *

Yes

Are you or anyone in your household working or going to school in person? *

Yes

If yes, what measures are being taken to ensure your/their safety there?

Have you been vaccinated? *

Yes - Both doses of Pfizer or Moderna or 1 dose of Johnson & Johnson received

Partially - 1st dose received, waiting for 2nd dose appointment

If yes, what was the date of your 2nd dose for Pfizer or Moderna or 1st dose for Johnson & Johnson?

Have you had COVID-19? *

Yes

If yes, when? Have you completely recovered?

Submit

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