Patient Name: _____________________________________   Date:__________________________________

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Please note that for the safety of our staff and other patients, all persons in FAMILY CARE ACUPUNCTURE AND HERBS must wear a face mask. Due to a worldwide shortage of medical masks, we ask that patients bring their own from home. Homemade masks are acceptable.

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Please answer the following questions. Check all boxes that apply:

□ Exposure to person with a lab-confirmed case of COVID-19 within the past 14 days

 

In the last 48 hours, have you experienced:

□ Fever over 100.5°F/38°C Current temperature ________________

□ New cough, shortness of breath, or difficulty breathing

□ New loss of sense of smell or change in taste

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If you check any of the boxes above, unfortunately we cannot treat you at this time. We will be happy to offer a telehealth consult, and/or refer you to an appropriate facility.

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In the last 48 hours, have you experienced:

□ New changes in skin (rash, skin discoloration, discoloration of toes) New chills, feeling cold, or shivering

□ New headache
□ New fatigue

□ Sore throat

□ Nausea/vomiting

□ Diarrhea

□ New nasal congestion or runny nose

□ New body or muscle aches

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If you check three (3) or more boxes above, unfortunately we cannot treat you at this time. We will be happy to offer a telehealth consult, and/or refer you to an appropriate facility.

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I acknowledge that the information provided above is correct:

Signed: _____________________________________ Date:_______________________________