Covid-19 Prescreening Questions - Center for Chiropractic + Wellness

First Name *

Last Name *

Prescreening Questions

Have you tested positive for Covid-19 in the last 14 days or was it recommended that you get tested? *

NoYesNo

Have you (or anyone you've been in close contact with) traveled outside of Oregon/Washington in the past 14 days? *

NoYesNo

Have you had contact with anyone who has been sick or confirmed positive for COVID-19 in the past 14 days? *

NoYesNo

Do you currently have or have you experienced any of the following in the past 14 days?

*Note: This list does not include all possible COVID-19 symptoms. We will update this list as new information is provided by the CDC.*

Please note that having a headache or muscle pain does not restrict you from coming in for your visit. If you have any doubts or concerns about your symptoms, please contact your provider or call the clinic prior to your scheduled appointment time to discuss. Thank you!

Possible Covid-19 Symptoms

Fever or chills? *

NoYesNo

Cough? *

NoYesNo

Difficulty breathing or shortness of breath? *

NoYesNo

Runny nose or congestion? *

NoYesNo

Sore Throat? *

NoYesNo

New loss of taste or smell? *

NoYesNo

Muscle or body aches? *

NoYesNo

Fatigue? *

NoYesNo

Nausea, vomiting or diarrhea? *

NoYesNo

Headache? *

NoYesNo

You need to answer all the mandatory questions to submit the form.

By submitting the form, you agree to our Terms of Service and Privacy Policy.

Submit

Covid-19 Prescreening Questions - Center for Chiropractic + Wellness

Thanks for completing the form.

The information has been received.

Did you enjoy the Colib experience?

Click the link below to learn how Colib can help you and your company with digital forms.

Thanks for completing the form.

The information has been received.

Did you enjoy the Colib experience?

Click the link below to learn how Colib can help you and your company with digital forms.

Prescreening Questions

Possible Covid-19 Symptoms

Let's view your own form now