SMPT COVID-19 Screening Form
StableMovement Physical Therapy is committed to ensuring the safety of our patients. Please be aware that the nature of in-person physical therapy services will not allow for social distancing. However, we do require patients and the physical therapist to wear a mask at all times. Please also fill out the following questionnaire and we will be in touch with you soon. Thank you!
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Email *
Have you received the Covid -19 vaccine? Name vaccine and # of doses with dates, if yes. *
Have you traveled outside of your hometown in the past 14 days? *
Have you had any fever, dry cough, shortness of breath, loss of taste/smell, or any other COVID-19 related symptoms? *
If you answered "yes" to the above question, please specify the details of your symptoms.
Have you been in contact with anyone who has tested positive for COVID-19? *
If you answered "yes" to the above question, please specify the date you came in contact with someone who has tested positive for COVID-19.
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Have you been tested for COVID-19? *
If you answered "yes" to the above question, please provide the date and result of your test.
Please list out any question or concerns you may have regarding your upcoming physical therapy visit.
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