CONFIDENTAL CLIENT COVID-19 PRE-SCREENING

•PLEASE FILL OUT THIS FORM AND RETURN IT TO YOUR THERAPIST NOT LESS THAN 24 HOURS BEFORE YOUR APPOINTMENT. IF YOUR CONDITION CHANGES FROM THE TIME THAT YOU SUBMIT THIS FORM TO YOUR THERAPIST AND BEFORE YOUR APPOINTMENT TIME, PLEASE RE-EVALUATE YOURSELF BEFORE ATTENDING THE APPOINTMENT.


•in adults: 38°C (100.4°F) and above (oral temperature)
•in older adults: 37.8°C (100°F) and above (oral temperature)
•in children: 38°C (100.4°F) and above
•or 1.1°C above the person's usual value


Are you experiencing any of the following?
•severe difficulty breathing (e.g., struggling for each breath, speaking in singlewords)
•severe chestpain
•having a very hard time waking up
•feelingconfused
•lost consciousness


Are you experiencing any of the following?
•shortness of breath atrest
•inability to lie down because of difficulty breathing
•chronic health conditions that you are having difficulty managing because of your current respiratory illness


Do you have any of the following?
•fever
•new onset of cough or worsening of chronic cough
•new or worsening shortness of breath
•new or worsening difficulty breathing
•sore throat
•runny nose


Do you have any of the following?
•chills
•painful swallowing •stuffy nose
•head ache
•muscle or joint ache
•feeling unwell, fatigue or severe exhaustion
•nausea, vomiting, diarrhea or unexplained loss of appetite
•loss of sense of smell ortaste
•conjunctivitis (pinkeye)



If you answered yes to any of these questions you are absolutely contraindicated for massage or manual osteopathic treatment. You must call to cancel your appointment. You may need to self-isolate. It is recommended that you immediately contact your local health authority and follow their instructions.


You have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.
•Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.
•Practice good hygiene: wash hands often, cover coughs and sneezes, and avoid touching your face.
•Monitor for COVID-19 symptoms: fever, cough, shortness of breath, sore throat or runny nose.
•If you do develop any COVID-19 symptoms, stay home and take this self-assessment again.


Confidential History
In order to protect yourself, your therapist, health, and other, honest disclosure is essential.

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