Dr. Vivian Giannakakis

Family Chiropractor

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COVID-19 Pre-Visit Screening Survey

As an essential healthcare worker, Dr. Vivian Giannakakis, D.C. must do everything possible to mitigate risk to patients and other members of the community so it is vitally important for you to complete this form as accurately prior to each visit. It is essential too text the office address if you are running late or early as to prevent excess overlapping with other people in the office.

Name

Select a date

Have you been exposed to COVID-19 or do you believe that you have been exposed?

Yes

No

Please check any of the following symptoms you are currently expressing:

Fever

Cough

Sore throat

Shortness of breath

Severe fatigue

Unsual body ached

Nausea

Loss of taste or smell

None of the Above

Have you traveled to or from a high risk geographic area in past 14 days?

Yes

No

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

By checking you are attesting that everything you stated above is truthful and accurate to the best of your knowledge.

Thank you for submitting