HEALTH SCREENING FORM

Please complete the below form prior to performing in-person sessions at any of the Revive offices.

Have you or anyone in your household tested positive for COVID-19?

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Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?

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To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

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Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

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Are you or anyone in your household a health care provider or emergency responder?

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Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

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Have you or anyone in your household traveled out of state in the past 21 days?

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STAFF PROCEDURES

After completing a treatment session you agree to clean with disinfectant wipes all doorknobs, chairs, and tables in any room or space used during the session.

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After completing a treatment session you agree to clean with appropriate disinfectant any utensils, cups, and similar items used by yourself or a client.

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While in the office you agree to follow the mandatory state health & safety requirements, including wearing a face mask?

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Additional Comments

Staff Name *

Date *

Signature *

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