Screening Questionnaire | familyosteo

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Covid-19 Screening Questionnaire and Health Declaration

How are you feeling today?

First Name

Last Name

Email

I currently should not be in isolation for any reason or have not travelled interstate or overseas in the last 14 days

I am not experiencing any of these the symptoms: fever, cough, sore throat or shortness of breath

I haven’t diagnosed with or been in close contact with someone diagnosed with COVID-19 in the last 14 days

Initials

Date

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

Thank you for submitting the questioonaire. Please contact Justin, our Principle Osteopath, on 0407 266 300 to discuss with him your questionnaire.

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