PATIENT HEALTH QUESTIONNAIRE
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Name
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Format: (000) 000-0000.
Prior to the start of my service, I confirm and understand that:
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I do not have a pending COVID-19 test.
I have not been diagnosed with or cared for anyone with COVID-19 in the past 2 weeks.
I have not shown signs or been in close contact with anyone that is exhibiting these symptoms: COUGH, FEVER/CHILLS, SHORTNESS OF BREATH, DIFFICULTY BREATHING, SORE THROAT, LOSS OF TASTE OR SMELL, FATIGUE, HEADACHE, CONGESTION, OR RUNNY NOSE, NAUSEA OR VOMITING OR DIARRHEA
I have not traveled outside of my immediate daily routine for the past two weeks.
If I begin to show symptoms of COVID-19 within the next two weeks, I will contact my Peristeam Hydrotherapy practitioner.
I will follow all posted facility rules to keep myself, my practitioner, and those around me safe.
PeriSteam Atlanta cannot be held liable from any exposure to the Coronavirus (COVID-19) caused by misinformation on this form or the health history provided by each patient.
If I take any steps to make a claim for damages against PeriSteam Atlanta, its agents, employees or any other released parties, I shall be obligated to pay all attorney’s fees and costs incurred as a result of such claim.
WARNING: Under Georgia law, there is no liability for an injury or death of an individual entering these premises if such injury or death results from the inherent risks of contracting COVID-19. You are assuming this risk by entering these premises.
Any person entering the premises waives all civil liability against this premises owner and operator for any injuries caused by the inherent risk associated with contracting COVID-19 at public gatherings, except for gross negligence, willful and wanton misconduct, reckless infliction of harm, or intentional infliction of harm, by the individual or entity of the premises.
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