Blossom Health Screening Questionnaire Prior to All Appointments:

 

This Blossom Screening is being used for the health safety of all concerned as we navigate this time of emergence in regards to the pandemic and California chiropractic best practices. 

 

Thank you for your cooperation. 

 

If you are a “Yes” to any question, please let us know and we are happy to reschedule your appointment to a future date.

In the past 30 days, have you experienced any cold or flu-like symptoms that may include: fever of 100.4 or greater, headache, dry cough, runny nose, extreme fatigue, shortness of breath or body aches? 

___Yes     ___No      

                                 

In the past 30 days, has anyone in your family or with whom you reside experienced any cold or flu-like symptoms that may  include: fever of 100.4 or greater, headache, dry cough, runny nose, extreme fatigue, shortness of breath or body aches?    ___Yes     ___No        

                     

In the past 30 days, have you been exposed to any other person who was known then or has since experienced any cold or flu-like symptoms including: fever of 100.4 or greater, headache, dry cough, extreme fatigue, shortness of breath or body aches?    

___Yes     ___No    

In the last 30 days, have you been exposed to anyone who has tested positive for COVID-19?

                                    ___Yes     ___No

Does any of the following apply to you?                    ___Yes     ___No

  • Are you over the age of 75?

  • Are you receiving chemotherapy, radiation therapy or dialysis?

  • Are you an organ transplant recipient?

  • Do you know yourself to be immunocompromised?

  • Do you have any chronic respiratory or lung infection or disease?

Have you traveled outside the country in the last 30 days?         ___Yes     ___No 

 

Have you gathered with others outside of the people you are sheltering in place with without using social distancing guidelines of 6 feet apart and face masks  in the past 30 days?     ___Yes     ___No

 

Thank you for your honest reflection in answering as we work to create a healthy opportunity for our clients to receive care at this time, while we also continue to protect proximity to our loved ones who are immunocompromised.

 

We also thank you for wearing a face covering while you are at your appointment. 

- Dr. Rhea and Dr. Austin

Speak directly to Dr. Austin or Dr. Rhea to see if we are a good fit to help you on your healing, pregnancy, or family wellness journey.
 Text or Call: 707-257-1011

© 2016