Dopps Chiropractic

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913-608-5441

COVID-19 PRE-VISIT SCREENING SURVEY

Dopps Chiropractic has been able to continue to serve our community with necessary chiropractic care. As such, we must do everything possible to mitigate risk to our staff and other members of the community so it is vitally important to you complete this form accurate prior to each visit.

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Select a date

Have you been exposed to COVID-19 or do you believe that you have? □Yes □No Please check any of the following symptoms you(or other members of your family that also have an appointment) are expressing

Yes

No

Shortness of breath

Productive cough

Non-Productive cough

Bronchitis

Respiratory infection

Sore throat

Fever or Chills

Nausea

Vomiting

Diarrhea

Severe fatigue (not related with travel)

New loss of smell or taste

None of the above

Have you traveled to or from a high-risk geographic area in the past 14 days? Cruise Ship, River Cruise or Traveled Internationally

Yes

No

If you are visiting Dopps Chiropractic with other family members, please list their names and which symptoms listed above (if any) they are currently experiencing:

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Your Signature