COVID-19 Wellness Screening
Name
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First Name
Last Name
Today's Date
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-
Month
-
Day
Year
Date
Do you have a cough?
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Yes
No
Do you have a fever now or have you in the last 14-21 days?
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Yes
No
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
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Yes
No
Are you experiencing shortness of breath or difficulty breathing?
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Yes
No
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
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Yes
No
Have you experience recent loss of taste or smell?
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Yes
No
Are you over the age of 60
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Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
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Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
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Yes
No
Informed Consent | COVID-19 Risk
I understand that I am choosing to come to the clinic for physical therapy/occupational therapy in spite of the risk of contracting COVID-19. I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that providers and all the staff at Rue and Primavera Occupational and Physical Therapy (R&P) are closely monitoring this situation and have put in place preventive measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected withCOVID-19 by virtue of proceeding with therapy/EMG study. I hereby acknowledge and assume the risk of becoming infected with COVID-19. I understand that I am at greater risk for contracting COVID-19 if I am: over 60 years old and/or have an underlying health condition including; diabetes, lung disease, heart disease and/or an auto immune disease.
Please let us know if you would rather NOT come into the clinic and would prefer virtual therapy. Please note not all therapy sessions are available for virtual therapy.
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Yes, I want virtual therapy
No I do not want virtual therapy, I want to come in the clinic
Signature Giving Consent to Treat During COVID-19 Risk
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