Patient Name: _____________________________________   Date:__________________________________

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.

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

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.

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

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.

I acknowledge that the information provided above is correct:


Signed: _____________________________________ Date:_______________________________

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