COVID Pre- Treatment Questionnaire

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This must be completed within 24 hours of your scheduled appointment

Name *

Date (must be filled out within 24 hours of your appointment) *

YYYY

Phone Number (best to reach you evening or afternoon before your appointment) *

Age *

Any new medications / supplements/ herbs that you haven't listed before? *

Please list any preexisting health conditions or significant past health conditions. (you only have to fill out this question on your first pre- treatment questionnaire)

Please check if you are experiencing any of the following symptoms of COVID - 19 *

Fever

Cough

Shortness of Breath or Difficulty Breathing

Chest Tightness

New Loss of Taste or Smell

Sore Throat

Chills

New Widespread Muscle Aches

Bluish / purplish fingers, toes, OR calf pain, redness, swelling & inflammation

Pronounced Fatigue

Diarrhea, Nausea or Vomiting

Congestion, Runny Nose or Sneezing

I AM NOT EXPERIENCING ANY OF THESE SYMPTOMS

Other:

Required

In the last 12-14 days, have you had any known exposure to someone who has tested positive for Covid - 19 in the last three weeks? Or someone who was symptomatic and had suspected Covid?

Have you attended large indoor gatherings unmasked in the last week?

Have you had a recent Covid test and if so when? and what was the result? Have you ever tested positive for Covid? If so, when?

Have you been Vaccinated? If so, please provide dates and what vaccine (Moderna, Pfizer, J & J). Have you completed both doses?

Have you traveled outside of the United States within the last 21 -31 days? If so, where? and when? (Please note depending on risk factors, treatment may be postponed to a later date) *

Have you traveled domestically in the last 10- 14 days by plane, train, bus, or utilized mass transit? If so please list here. (Please note, depending on risk factors, treatment may be postponed to a later date) *

By checking the box below, I acknowledge that (excepting a medical condition) that I am being asked to arrive at treatment with a mask on and to wear mask during intake and treatment (unless otherwise discussed) and that treatment may be denied if I choose not to wear a mask. If I do not have a mask, one can be provided to me for an additional cost. *

I acknowledge the above

Required

I acknowledge that upon arrival my temperature may be take (via touchless thermometer) and that I may be denied treatment and sent to PCP if these readings are concerning or if I arrive a the office with visible signs of an active respiratory infection. *

I acknowledge the above

Required

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