COVID-19 Pre-Visit Questionnaire
Healy Chiropractic LLC
Date of Birth
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”.
New Loss of Smell or Taste
Repeated Shaking with Chills
None of the Above
Are you currently having any of the following symptoms? If you are not having any of the following symptoms check “None of the Above”.
Confusion or New Brain Fog
Bluish lips or face
Persistent pain or pressure in the chest
New, Persistent lethargy
None of the above
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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