Journeys OT & Wellness - COVID-19 intake form
Due to the COVID-19 pandemic, we are requiring this intake form before each session.

Please fill out the form the evening before of your appointment so your practitioner has time to review and contact you if there is a need to reschedule.

If you experience any symptoms on the day of your appointment, please text your practitioner to reschedule.
Email address *
First Name *
Last Name *
In the past 4 days, have you experienced any of the following (check any that apply): *
Have you been tested for active COVID-19 (not an antibody test)? *
If you answered yes for the previous question, what was the date of your test?
In the past two weeks, have you been in any groups of people greater than 10 where social distancing was not observed? *
Social distancing includes maintaining 6 feet away from others, washing/sanitizing hands, and wearing a face mask.
Are you aware of having been exposed to someone with COVID-19 or anyone who has been exposed to someone with COVID-19 in the past 2 weeks? *
Have you traveled to any places with a high infection rate in the past 2 weeks? *
I have answered these questions truthfully and understand that people with COVID-19 can be asymptomatic and still contagious. *
Never submit passwords through Google Forms.
This form was created inside of Journeys Occupational Therapy LLC. Report Abuse