COVID-19 Pre-Visit Questionnaire
Healy Chiropractic LLC
Email address *
First Name *
Last Name *
Date of Birth *
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Have you been diagnosed with or been in contact with anyone diagnosed with COVID-19 caused by the novel Corona Virus in the past 14 days? *
Have you had a cough, shortness of breath, or difficulty breathing at any time in the past two weeks? *
Please check any symptoms that you have had over the past two weeks; if you have not had any of the following symptoms check “None of the Above”. *
Required
Are you currently having any of the following symptoms? If you are not having any of the following symptoms check “None of the Above”. *
Required
Have you traveled outside of Maine in the past two weeks? *
Please share explanation or existing diagnosis that may explain your answers to previous questions. (Optional)
By typing my full legal name below, I acknowledge that the above information is factual. *
A copy of your responses will be emailed to the address you provided.
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