Client COVID-19 Self Screening Questionnaire

Client COVID-19 Self Screening Questionnaire

Be Moved Therapy LLC
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location at 1895 Centre St. If you answer “YES” to any of the questions, please DO NOT come to the building. If you experience any symptoms or answer “YES” to any of these questions, please email kimberly@bemovedtherapy.com. If you are well enough to participate in therapy your session will be moved online. If you are not well your appointment will be rescheduled at no charge.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

2) If you are not fully vaccinated, in the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Have you traveled internationally in the last 10 days?

If you answered “Yes” to any part of question two, please DO NOT come into our building and contact kimberly@bemovedthearpy.com. I certify to the best of my knowledge; this information is accurate.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: