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.
In the past 4 days, have you experienced any of the following (check any that apply):
shortness of breath
sudden loss of taste or smell
nasal or sinus congestion
sudden onset body aches
new rash or other changes to your skin
sores on toes
I have not had any of these symptoms
Have you been tested for active COVID-19 (not an antibody test)?
Yes, and I tested positive
Yes, and I tested negative
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.
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This form was created inside of Journeys Occupational Therapy LLC.