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.
Check the appropriate boxes below if you have had any of these symptoms in the past two weeks.
Shortness of breath
New head or body aches
New Loss of taste or smell
I have not had any of the above symptoms
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.
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This form was created inside of Evolution Physical Therapy and Yoga Studio Inc.