AAA PT Health Screening Form

PATIENT & STAFF HEALTH SCREENING FORM

8975 Guilford Rd Ste 170, Columbia, MD 21046
Type of Visitor
If you are a returning patient, please verify the following information in WebPT and update if necessary:
- Phone number
- Email
- Address
For urgent concern purposes, please update the Emergency Contact fields below, if necessary.
Full Name/Visitor's Name:*

First NameLast Name
Company Name (Vendor)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number
Email*
example@example.com
Best way to contact you?*

EmailPhone CallText Message
Is there an update to your Emergency Contact?

Yes, I do.No, I don't have any updates.
In case of EMERGENCY, contact:*

First NameLast Name
Phone number of emergency contact:*

Area CodePhone Number
1. Have you been in close contact with someone known to have COVID-19 in the last 14 days?*

YesNoIn contact but not “close contact” - within 6 ft distance for at least 15 minutes
2. Have you personally had COVID-19? If so, have you been released by your physician to return to regular activities?*

YesNo
3. Have you been told by a public health official that you may have been exposed to COVID-19 in the last 14 days?*

YesNo
4. Have you experienced any of the following symptoms within the last 14 days? (Choose all that applies)

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea
5. Do you have any current symptoms of illness?*

YesNo
6. Have you been out of the Country in the last 30 days (if so where)?*

YesNo
Place of Travel
Example: China
7. Have you traveled elsewhere in the US in the past 21 days, (if so, where)?*

YesNo
Place of Travel
Example: Las Vegas
Remember when to seek Emergency Medical Attention.
Look for emergency warning signs* for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately.

Trouble breathing
Persistent pain or pressure in the chest
New confusion
Inability to wake or stay awake
Bluish lips or face

*This list is not all possible symptoms.

Please call your medical provider for any other symptoms that are severe or concerning to you.

Call 911 or call ahead to your local emergency facility: Notify the operator that you are seeking care for someone who has or may have COVID-19.
Date*

MonthDayYear
Date
What is your current body temperature (Farenheit)?*
98.6
Patient/Interviewer/Visitor Signature*

Clear
Please affix your signature inside the box
If patient is a MINOR, parent/guardian’s name:

First NameLast Name
Parent/guardian signature:

Clear
Please affix your signature inside the box

p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908

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PATIENT & STAFF HEALTH SCREENING FORM