Mandatory Covid-19 Screening
Patient Advisory and Acknowledgment:  Receiving Medical Treatment During the Covid-19 Pandemic

Dear Patient:
You are coming to our office for a routine medical evaluation and/or treatment that will be done
during the COVID-19 pandemic. Please be advised of the following:
While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.
In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Thank you.

NOTE: Federal, state and local guidelines are changing. Please continue to follow guidelines regarding travel, masks and social distancing.

Masks are required at all times at the office.


Please email Lisa@DavisSquareAcupuncture.com with any questions or concerns.
The Acupuncture Practice of Lisa Desrosiers, LAc
7 Central St, Ste 145, Arlington MA 02476
617-548-8167

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Name *
Today's Date *
DD
/
شهر
/
YYYY
Have you been fully vaccinated for more than 2 weeks?
محو التحديد
ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? *
HAVE YOU OR A HOUSEHOLD MEMBER OR CLOSE CONTACT RECEIVED A POSITIVE COVID-19 TEST OR PRESUMED POSITIVE CASE WITHIN THE LAST 14 DAYS?  (Close contact is defined as spending a total of 15 minutes within 6 feet of someone currently infected with Covid 19). *
DO YOU HAVE A FEVER? *
DO YOU HAVE ANY SHORTNESS OF BREATH? *
DO YOU HAVE A DRY COUGH? *
DO YOU HAVE A RUNNY NOSE? *
DO YOU HAVE A SORE THROAT? *
DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES? *
HAVE YOU EXPERIENCED NEW HEADACHES, FATIGUE, OR WEAKNESS? *
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL? *
ARE YOU HAVING NAUSEA, DIARRHEA, VOMITING, ABDOMINAL PAIN OR OTHER UNUSUAL GI /DIGESTIVE SYMPTOMS? *
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED TO ANY FOREIGN COUNTRY? *
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED WITHIN THE UNITED STATES? *
THIS QUESTION IS NO LONGER REQUIRED. PLEASE FOLLOW CURRENT GUIDELINES REGARDING MASKS AND SOCIAL DISTANCING. Have you socialized in the past 14 days with non-household members WITHOUT wearing a mask or social distancing? [If you are unvaccinated and have socialized indoors with non-household members without masks then wait 14 days after last contact before resuming acupuncture.]
محو التحديد
IF YOU ANSWERED 'YES' TO ANY QUESTIONS, PLEASE EXPLAIN.  
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