Covid

Client Questionaire COVID-19

Please fill out the below form before starting your treatment.

Select the Mommy Wellness branch you are visiting

Full Name

Telephone Number

Email Address

Date of Treatment

Do you have fever (temperature above 38 degrees Celsius, or have you felt hot or feverish recently (14-21 days)?
YesNo

What is your current temperature?

Do you have shortness of breath or any difficulties breathing?
YesNo

Do you have a cough?
YesNo

Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
YesNo

Have you experienced recent loss of taste or smell?
YesNo

Have you been in contact with any confirmed COVID-19 positive persons?
YesNo

Are you over 65 years of age?
YesNo

Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
YesNo

Have you traveled in the past 14 days to any regions affected by COVID-19?
YesNo