Coronavirus Disease 2019 – Patient Questionnaire Have you been fully vaccinated for two or more weeks?* Yes No You will be asked to complete this form at each visit or to verbally attest that none of the questions, listed on the Patient Questionnaire, have “yes” responses. Please check the Yes or No boxes; do not check both boxes. Feel free to explain what a yes or no answer means to the Screener. Please note: “Close Contact” means ≤ 6 feet for ≥ 15 minutes. 1. Have you traveled outside the local area in the past 14 days?* Yes No 2. Have you been in “close contact” with someone who has traveled outside of the local area in the past 14 days?* Yes No 3. Have you been in “close contact” with others at “in person” events or gatherings in the past 14 days?* Yes No 4. Have you been in “close contact” with an individual who has had any of these symptoms, in the past 14 days? 4.1 Fever over 100.4° or chills* Yes No 4.2 Persistent cough* Yes No 4.3 Shortness of breath/difficulty in breathing* Yes No 4.4 Fatigue* Yes No 4.5 New loss of taste or smell* Yes No 4.6 Sore throat* Yes No 4.7 Muscle or body aches* Yes No 4.8 Congestion or runny nose* Yes No 4.9 Nausea or vomiting* Yes No 4.10 Diarrhea* Yes No 4.11 Headaches* Yes No If yes, have they been diagnosed as positive for COVID-19? Yes No 5. Have you had any these symptoms in the past 14 days? 5.1 Fever over 100.4° or chills* Yes No 5.2 Persistent cough* Yes No 5.3 Shortness of breath/difficulty in breathing* Yes No 5.4 Fatigue* Yes No 5.5 New loss of taste or smell* Yes No 5.6 Sore throat* Yes No 5.7 Muscle or body aches* Yes No 5.8 Congestion or runny nose* Yes No 5.9 Nausea or vomiting* Yes No 5.10 Diarrhea* Yes No 5.11 Headaches* Yes No If yes, how long have you had these symptoms? If yes, have they been diagnosed as positive for COVID-19? Yes No If you answered “yes” to any of the questions above, we will work with you to make accommodations for therapy to the best of our ability based on the guidance from our local Public Health Department and/or your personal physician. Please contact us if you have questions. Thank you for assisting us in our endeavors to minimize exposure to COVID-19.Name* Date* MM slash DD slash YYYY Signature*
