Temporary Covid-19 Pre-Session Questionnaire

Discretion is respected and expected.  Any information shared is strictly confidential.

 

  1. Have you received a Covid-19 vaccine?  If so, which one and when did you receive it?

  2. Do you currently, or have you in the previous 30 days, had any symptoms of a cold or flu or loss of taste/smell?

  3. Do you currently, or have you in the previous 30 days, had any unusual physical symptoms of any kind?
  4. Have you tested positive for Covid-19 at any time?  If so, provide the date.

  5. When was the last time you travelled outside of the United States?

  6. When was the last time you were on an airplane?

  7. Have you been going in to work, or working remotely?

  8. How many people are in your household?

  9. If not alone, have any members of your household left the United States, travelled on an airplane, or displayed symptoms of a Covid-19 in the previous 30 days?

  10. Are there any children in your household that attend daycare or school in person?

  11. Have you been taking special precautions to limit exposure to Covid-19?  Please explain.

  12. Have you, to your knowledge, been in direct contact with anyone who has tested positive for Covid-19 in the last 30 days?

  13. If I see you for a session, do you understand that my tribute has temporarily increased  ($350) because of the associated risk and to accommodate special precautions that I must take?

  14. If I see you for a session, are you willing to be tested for Covid-19 3 days prior to the session?  I can provide information on free, drive-through testing options.