COVID-19 Pre-Screening Survey

Updated 3/16/2021

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!

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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

5. Are you fully vaccinated against COVID-19?

- 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.

- I will wait for a phone call before coming to the door for my appointment.

Questions? Please call or text Betsy at (971) 341-9546, or email betsygordon.LAC@gmail.com.