Covid-19 Pre-Screening Assessment Tool - Cornerstone Therapy & Wellness

Name *

First and Last Name

Email Address *

Date of Appointment *

(DD/MM/YYYY)

Do you have the following symptoms or signs? Check all that apply. *

2. Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)? *

Yes
No

3. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19 within the last 10 days? *

Yes
No

** Examples include: A positive test from a co-worker that you have been around in the last 10 days or being around a family member with flu/cold like symptoms in the last 10 days.

5. Are you or someone you live with awaiting the results of a Covid-19 test? *

Yes
No

In Person Treatment Consent *

I acknowledge and understand the presumed risk of having in person therapy.

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). Exposure to Covid-19 may result in adverse health effects that may require hospitalization, intubation/ventilator support, long-term health related risks (i.e lung dysfunction), or even death.