COVID 19 Questionnaire
Daily on-site treatment COVID form for PT360 sports medicine & spine therapy
Name *
Date completed *
MM
/
DD
/
YYYY
Have you had any of these symptoms? *
Yes
No
Fever of 99.6
Persistent Cough
Shortness of breath
Diminished Sense of Smell and/or Taste
If you answered yes to any of the above symptoms, how long have you had these symptoms, *and* have you been diagnosed and/or seen a physician?
Clear selection
Have you traveled outside of the US in past 30 days? *
If you answered yes to the above question, list the countries here.
Have you been in close contact with an individual who has traveled outside of the US in the past 30 days? *
If you answered yes to the above question, list the countries here.
Have you been in close contact, in the past 30 days, with an individual who has had any of these symptoms? *
Yes
No
Fever of 99.6
Persistent Cough
Shortness of breath
Diminished Sense of Smell and/or Taste
If you answered yes to any of the above questions, have they been diagnosed and/or seen the doctor? *
If you answered yes to any of the questions, we will work with you to make accommodations for therapy to the best of our ability. Please contact Shelly or Kristi at 503-248-0360 if you have questions.
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