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COVID-19 Pre-Visit Questionnaire
Healy Chiropractic LLC
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Have you been diagnosed with or been in contact with anyone diagnosed with COVID-19 caused by the novel Corona Virus in the past 14 days?
*
Yes
No
Other:
Have you had a cough, shortness of breath, or difficulty breathing at any time in the past two weeks?
*
Yes
No
Other:
Please check any symptoms that you have had over the past two weeks; if you have not had any of the following symptoms check “None of the Above”.
*
Fever
Muscle Pain
New Loss of Smell or Taste
Chills
Headache
Repeated Shaking with Chills
Sore Throat
None of the Above
Required
Are you currently having any of the following symptoms? If you are not having any of the following symptoms check “None of the Above”.
*
Trouble Breathing
Confusion or New Brain Fog
Bluish lips or face
Persistent pain or pressure in the chest
New, Persistent lethargy
None of the above
Required
Have you traveled outside of Maine in the past two weeks?
*
Yes
No
Please share explanation or existing diagnosis that may explain your answers to previous questions. (Optional)
Your answer
By typing my full legal name below, I acknowledge that the above information is factual.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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