Balance Health & Injury Clinic Pre-visit Questionnaire
Covid-19 Screening Questions & Clinic Information and Policies Agreement
In order to maintain confidentiality, please enter your5-digit pin code *
Covid-19 Required Questions
The following questions are required by the Oregon Health Authority (OHA), Occupational Safety and Health Administration (OSHA), and the Governor of the State of Oregon.
Have you experienced any of the following symptoms within the last 48 hours: fever or chills; cough; shortness of breath or difficulty breathing; fatigue; muscle or body aches; headache; NEW loss of taste or smell; sore throat; congestion or runny nose; nausea and/or vomiting; diarrhea? *
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone with symptoms listed above, diagnosed as Covid-19 or not? *
Are you isolating or quarantining because you may have been exposed to a person with Covid-19 or are worried that you may be sick with Covid-19? *
Are you currently waiting on the results of a Covid-19 test? *
Office Policies and Procedures
Please indicate that you have read, understand, and will comply with the below listed Office Policies and Procedures.
NO LOBBY: Due to social distancing rules in Oregon we do not currently have a waiting room. All paperwork must be completed and submitted in advance of visit. *
APPOINTMENT TIMES: In order to maintain the level of care that our patients deserve, and to appropriately schedule "distanced" arrival and departure, it is important that you are on time for your appointment. Being even one minute late may require us to reschedule your visit. *
MASK RULES: In accordance with state guidelines, masks are required for entrance to the clinic. A mask will be provided if you do not have one. Masks must be worn at all times unless directed to remove by your doctor/provider. *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy