Covid-19 Wellness Pre Screening Questionnaire

Mandatory COVID-19 Wellness Pre-Screening Questionnaire

You must complete this screening questionnaire before each appointment. Savvy Intuition, LLC reserves the right to cancel your appointment without the completion of this form prior to your session.
Client Name*

First NameLast Name
By checking the boxes, you confirm that you agree with the following statements:*

I agree to obey the rules of the practice during my appointment in order to minimize the spread of viruses.I confirm that I have not been diagnosed with COVID-19 last 14 days.I verify that I am not waiting for the laboratory test results for COVID-19.
Do you have any of these symptoms? - cough, shortness of breath, high fever or chills, muscle pain, body ache, nausea, new loss of taste/smell, headache, sore throat, congestion or runny nose, vomiting, or diarrhea*

YesNo
Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or diagnosed with COVID-19?*

YesNo
Are you living with anyone that is infected or quarantined due to COVID-19?*

YesNo
In the past 14 days have you had close contact with anyone who has travelled to any other states or any other country?*

YesNo
In the past 14 days have you visited any other states?*

YesNo
If yes, list every state you have visited in the past 14 days:*
Type N/A if not applicable
In the past 14 days have you visited any other countries?*

YesNo
If yes, list every country you have visited in the past 14 days*
Type N/A if not applicable
I agree not to visit the practice for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.
Parent/Guardian Name (if applicable)

First NameLast Name
Date*

MonthDayYear
Date
Please sign your full name to confirm that all information provided on this form is true to the best of your knowledge.
Client/Parent/Guardian Signature*

Clear
Please complete this questionnaire again if any of your answers change before your appointment.

Did you answer yes to any questions?

If you answered YES to any of the questions above, contact Chey-Anne directly to discuss telehealth options until you or those around you are symptom free. Thank you.
Your information will be encrypted.
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Mandatory COVID-19 Wellness Pre-Screening Questionnaire