COVID-19 Questionnaire

Name *

Date *

Please select Yes or No. Feel free to explain what a yes or no answer means in the Comment Section below the question.

Have you traveled outside of the US in past 30 days?

Yes

Comment – Have you traveled outside of the US in past 30 days?

Have you been in close contact with an individual who has traveled outside of the US in the past 30 days?

Yes

Comment – Have you been in close contact with an individual who has traveled outside of the US in the past 30 days?

Have you been in close contact, in the past 30 days, with an individual who has had any these symptoms? – Fever Over 104°, Persistent Cough, Shortness of Breath

Yes

Comment – Have you been in close contact, in the past 30 days, with an individual who has had any these symptoms?

Have you had any these symptoms?- Fever Over 104°, Persistent Cough, Shortness of Breath

Yes

Comment – Have you had any these symptoms?- Fever Over 104°, Persistent Cough, Shortness of Breath

If you answered yes to any of the questions above, we will work with you to make accommodations for therapy to the best of our ability.

Thank you for assisting us in our endeavors to minimize exposure to the Coronavirus 2019.

FLUSHING

GLEN OAKS

SOUTH RICHMOND HILL

MASSAPEQUA

SOUTH OZONE PARK

ELMHURST

JAMAICA