COVID-19 Pre-Screening Survey

Updated 2/3/2021

You'll receive an automated email 36 hours prior to your in-office acupuncture visit which prompts you to complete the brief survey below.

Read about my updated procedures and precautions here. I welcome you to contact me with any questions!

In the last two weeks, have you or anyone you have been in close contact with ...

1. ... had contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?*

- Yes

- No

2. ... experienced any of the following symptoms? (* - not related to a pre-existing condition)*

- New cough*

- New shortness of breath*

- Difficulty breathing

- New fever, or feeling feverish

- New chills, or repeated shaking with chills

- New fatigue*

- New body aches or muscle pain not caused by a specific activity such as exercise

- New diarrhea*

- New nasal congestion*

- New sore throat*

- New loss of taste or smell

- I have not experienced any of these symptoms.

3. ... travelled outside of Oregon?*

- Yes

- No

If yes, please explain the nature of your travel.

4. ... gathered indoors in a group of six or more, or with members of more than two households?*

- Yes

- No

If you answered "yes" to question 1, 3, or 4, or have checked present symptoms, Betsy may contact you to reschedule your appointment. You will not be charged a fee.

Updated Procedures

Please check to acknowledge each of the following appointment procedures.*

- I will wear a mask for the duration of my visit to Betsy Gordon Acupuncture.

- I will wear or bring loose clothing to allow comfortable access to any areas of pain.

- I understand Betsy will call my cell phone at my appointment time to discuss updates and goals for treatment. I understand I am encouraged to wait in my parked car. (If I am walking, biking, or taking public transportation, I understand I am encouraged to contact Betsy to schedule this conversation earlier in the day.)

- I will use hand sanitizer upon entering and immediately following my appointment.

Questions? Please call or text Betsy at (971) 341-9546, or email

  • Facebook
  • Twitter
  • Pinterest
  • Instagram

© 2020 Betsy Gordon Acupuncture. All Rights Reserved.