Date (must be filled out within 24 hours of your appointment) *
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YYYY
Phone Number (best to reach you evening or afternoon before your appointment) *
您的回答
Age *
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Any new medications / supplements/ herbs that you haven't listed before? *
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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)
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Please check if you are experiencing any of the following symptoms of COVID - 19 *
必填
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?
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Have you attended large indoor gatherings unmasked in the last week?
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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?
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Have you been Vaccinated? If so, please provide dates and what vaccine (Moderna, Pfizer, J & J). Have you completed both doses?
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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) *
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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) *
您的回答
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. *
必填
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. *