COVID-19 Pre-Screening Survey


Updated 9/15/21


You'll receive an automated email 36 hours prior to your appointment 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 ...


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

- Yes

- No


If yes, please contact me at (971) 341-9546 or betsygordon.LAC@gmail.com. I may choose to reschedule your appointment but you won't be charged a fee.


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.


If you select present symptoms, please contact me at (971) 341-9546 or betsygordon.LAC@gmail.com. I may choose to reschedule your appointment but you won't be charged a fee.


3. Are you fully vaccinated against COVID-19?

- Yes

- No


4. If no, have you travelled outside of Oregon?

- Yes

- No


If yes, please contact me at (971) 341-9546 or betsygordon.LAC@gmail.com. I may choose to reschedule your appointment but you won't be charged a fee.


Thank you!