Coronavirus Disease 2019 – Patient Questionnaire

  • 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.
  • 4. Have you been in “close contact” with an individual who has had any of these symptoms, in the past 14 days?
  • 5. Have you had any these symptoms in the past 14 days?
  • 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.
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