Watershed Wellness COVID-19 screening questionnaire
We are using this questionnaire to help speed up & simplify our required COVID-19 screening process. This form, despite being hosted by Google, is as secure as it gets for such things online. We have a special Google account that adheres to the standards of HIPAA, the same protocol that governs all the software and processes even the largest medical centers must utilize. Thanks for your cooperation!

--------------------------------- PLEASE READ THE BELOW FIRST ------------------------------------------

I understand that I am the decision maker for my health care. Part of Watershed Wellness' role is to provide me with information to assist me in making informed choices. This process is ofƚen referred ƚo as informed consent, and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

Our staff are symptom free and regularly screened, and to the best of our knowledge, are not carrying the virus. However, since we are a place of public accommodation, other persons could be infected, with or without their knowledge. No business, healthcare related or not, can guarantee a zero risk environment.

In order to reduce the risk of spreading COVID-19, we ask you to answer the screening questions below to help us determine whether you might be at higher risk of carrying the virus into our facility. If you fall into a high risk group based on your answers, we will need to reschedule your appointment appropriately and we will offer you supportive resources for your care. Front desk staff and ownership will discus options with you if that is the case.

This data will be saved in a secure spreadsheet, along with all of our other patient data, and your body temperature on entry recorded with it. Keeping the data this way is required for liability purposes.

What is your name? *
Have you tested positive for COVID-19 at any time? *
Are you currently awaiting the results of a COVID-19 test? *
Do you currently feel feverish? *
Do you have any shortness of breath not related to a preexisting condition? *
Do you have a dry cough not related to a preexisting condition? *
Do you have sneezing, watery eyes, a sore throat, runny nose or sinus pain that is not related to seasonal allergies or another known condition? *
Have you lost your sense of smell or taste in the last 14 days? *
Within the last 14 days have you travelled outside of the United States? *
Within the last 14 days have you travelled outside of Oregon or Washington, but in the US? *
Do you certify your answers above are true to the best of your knowledge? *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Watershed Wellness - Astoria. Report Abuse