Covid-19 Symptom Questionnaire
Have you had any of these symptoms in the past 2 weeks? If yes to any of these questions, please contact your physical therapist to reschedule your appointment.
Name *
*
MM
/
DD
/
YYYY
Check the appropriate boxes below if you have had any of these symptoms in the past two weeks. *
Required
Have you been exposed to someone who has COVID-19 in the past 2 weeks *
Have you traveled out of state in the past two weeks? *
Please take your temperature before leaving your house for your appointment. Fill in your temperature below. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Evolution Physical Therapy and Yoga Studio Inc. Report Abuse