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Covid19 Screening
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Covid19 Screening

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Has the patient or anyone in the family (household) tested positive for COVID-19?

Yes

Has the patient or anyone in the family (household) been tested for COVID-19 and are awaiting results?

Yes

Does the patient or anyone In the family (household) have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?

Yes

Has the patient or anyone in the family (household) recently lost your senses of smell or taste?

Yes

Has the patient or anyone in the family (household) have any GI symptoms? Diarrhea? Nausea?

Yes

Even if you don't currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days?

Yes

Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?

Yes

Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?

Yes

Has the patient or anyone in the family (household) traveled within the United States by air, bus or train within the past 14 days?

Yes

a team member of Little Tesla Pediatric Therapy will reschedule your child(ren)'s therapy appointment. Please contact your doctor for further advice.

If you do not meet the criteria above, please sign below indicating that you have been provided with this information.
I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN) AND I DO NOT HAVE SYMPTOMS AS DESCRIBED. (Please list the full name and date of birth of each child present at today's appointment.)

Patient Name(s)

Date of Birth

Legal Guardian Name

Relationship to Patient(s)

Surename

Current date

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