Ultimate U Pre-Visit Health Questionnaire

  • Ultimate U Visit Health Questionnaire

    Wellness Services in the Era of COVID-19

  • If you have been exposed to a communicable disease, you may spread the disease to your Ultimate U service provider, other Ultimate U staff or other visitors to our facility.  To minimize that risk, State mandates require us to ask you the following questions prior to each visit. This typicallys takes about 10 seconds.

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  • Do you or others accompanying you to your visit to Ultimate U today, or anyone you have recently been in contact with have any of the following symptoms?

  • Fever (temperature above 100.4 degrees)?*
  • Cough?*
  • Shortness of breath and/or trouble breathing?*
  • Persistent pain, pressure or tightness in the chest?*
  • Have you or others accompanying you to today's visit or anyone you have recently been in contact with, tested positive for, or been diagnosed as having COVID-19 or any other communicable disease?*

  • Provide approximate dates of illness below.

  • Should be Empty: