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YOUR CART
Entry Screening
Completed by therapist in person prior to client entry to facility.
*
Indicates required field
Name
*
First
Last
Who is checking in?
*
Client
Therapist
In the last 10 days, have you or anyone you have been in close contact with, not felt well: headaches, cough, flu like symptoms, or diagnosed with covid?
*
Yes
No
In the last 21 days have you tested positive for covid?
*
Yes and received a follow-up negative covid test results. - Allow entry.
Yes and did not receive a follow-up negative covid test result. - Deny entry.
No
If YES to any prior question, do not allow entry or provide reasoning for allowing entry.
*
Denied entry.
All is well so far, continuing pre-entry screening.
Notes / Actions taken
*
Length of stay
*
30 - 45 minutes
60 - 75 minutes
90 - 105 minutes
2 hours
7:30am - 2:00pm work
2:00pm - 9:30pm work
7:30am - 9:30pm work
Temperature
*
Submit
