COVID19 Symptom Form

Client Name

First NameLast Name

Type a question*

Rows	PRE-APPOINTMENT Yes	PRE-APPOINTMENT No	IN-OFFICE Yes	IN-OFFICE No
Do you have a fever or have you felt hot or feverish recently (14-21 days)?
Do you have shortness of breath or other difficulties breathing?
Do you have a cough?
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Have you been in contact with any confirmed COVID-19 positive patients?
Have you tested positive for COVID-19 in the last 14-21 days?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Positive responses to any of these would likely indicate a deeper discussion with your therapist before proceeding with treatment.

• For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.