Patient COVID Health Check - Carabasi Chiropractic Center

Today's Date*

MonthDayYear

Name*

First NameLast Name

EMERGENCY SYMPTOMS - Do you have ANY of the following (Check ALL that apply)*

Bluish lips or faceSevere and constant pain or pressure in the chestExtreme difficulty breathing (such as gasping for air, being unable to talk without catching your breath, severe wheezing, nostrils flaring)New disorientation (acting confused)Unconscious or very difficult to wake upSlurred speech or difficulty speaking (new or worsening)New or worsening seizuresSigns of low blood pressure (too weak to stand, dizziness, lightheaded, feeling cold, pale, clammy skin)Dehydration (dry lips and mouth, not urinating much, sunken eyes)None of the above

Within the last 10 days have you been (A) diagnosed with COVID-19, OR (B) had a test confirming you have the virus, OR (C) been advised to self-isolate or quarantine by your doctor or a public health official?*

YesNo

What date was your positive test administered (not the date you received your result)? OR (if you did not test positive) What date did your self-isolation/quarantine begin?

MonthDayYear

You answered "YES" to a COVID question that requires you to self-isolate or quarantine for ten days, starting: {whatDate48}.

Please call us (856) 983-3373 so we can reschedule your treatment for a date after your quarantine/self-isolation ends.

In the last two weeks, were you within 6 feet of a COVID-19 infected person for more than a cumulative total of 15 minutes or more over a 24-hour period or have you had direct contact with infectious secretions (e.g., were coughed on)?*

YesNo

What is the date of the LAST close contact with the infected person?

MonthDayYear

You answered "YES" to a COVID question that requires you to self-isolate or quarantine for ten days, starting: {whatIs}.

Please call us (856) 983-3373 so we can reschedule your treatment for a date after your quarantine/self-isolation ends.

In the last two weeks, did you live in the same house as someone who was confirmed to have COVID-19?*

YesNo

What is the date that the person you live with began self-isolation?

MonthDayYear

You answered "YES" to a COVID question that requires you to self-isolate or quarantine for ten days, starting: {whatIs46}.

Please call us (856) 983-3373 so we can reschedule your treatment for a date after your quarantine/self-isolation ends.

Do you have a Headache?*

YesNo

Are you experiencing any of the following symptoms today? Choose all the apply. Leave empty if none of these apply to you.*

What date did your symptom(s) begin?

MonthDayYear

You answered "YES" to a COVID question that requires you to self-isolate or quarantine for ten days, starting: {whatDate}.

Please call us (856) 983-3373 so we can reschedule your treatment for a date after your quarantine/self-isolation ends.

How old are you?*

How many other people do you live with?*

Chronic Medical Conditions*

Select the icon that best reflects your present state of mind*

Signature

Carabasi Chiropractic Center

STOP - if you selected ANY of the emergency symptoms, CALL 911

How do you feel today?