Provider Covid-19 Screening Form

The State of NY mandates that providers must complete a health screening assessment DAILY before they are allowed to see their scheduled patients. Please complete the below questionnaire. Thank you.

Is your temperature today under 100.5 degrees?

Yes

No, my temperature today is at or above 100.5 degrees and I must stay home

Clear selection

Have you tested positive for Covid-19 through a diagnostic test in the past 14 days? *

Yes, and I must stay home

Have you experienced any of the following COVID-19 symptoms in past 14 days? *

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or boy aches

Headache

New loss of taste or smell

Sore throat

Congestion

Runny nose

Nausea

Vomiting

Diarrhea

NONE OF THE ABOVE

Required

Have you knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of Covid-19? *

Yes, and I must stay home

If you have traveled outside of NYS or outside a state that shares a border with NY within the past 14 days, have you tested negative for Covid-19?

Yes

No, and I must stay home

Clear selection

I have brought my own clean required PPE today and/or I have access to the required PPE to treat my clients today. *

Yes

No, and I must stay home

I confirm that the information given in this form is true, complete and accurate. I agree to follow all NYS Guidelines regarding Massage Therapy and agree to abide by the Hand in Health NY Forward Safety Plan. I understand that any misrepresentation, falsification, or omission of any facts may result in cancellation of your Provider Agreement. *

I confirm the above.

Required

Submit

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