Pre-screen | Find Your Inner Zen

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NEW PRE-SCREEN for all in-person appointments

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PRE-SCREENING FORM

Pre-screening Questionnaire

First Name

Last Name

E-mail

Have you tested positive for any type of contagious infection in the past 14 days or have you had contact with a person with a contagious infection without wearing appropriate PPE?

Yes

No

Are you experiencing or have you experienced any of the following in the past 14 days, including fungal, viral or bacterial infections:

Fever

Cough, sore throat, chronic cough worsening, difficulty breathing or shortness of breath, difficulty swallowing, hoarse voice

Sneezing, runny nose or nasal congestion (especially if cause is unknown or lost sense of smell or taste

Cold, flu, bronchitis, pneumonia, etc.

Headache or migraine

Chills, body aches, or feeling unwell, unexplained fatigue

Digestive issues (nausea, vomiting, diarrhea, stomach pain)

Pink eye (conjunctivitis)

Contagious skin infection (such as shingles, Athlete's foot, toe nail fongus,etc.)

Any active infection of any kind, including a tooth infection.

None of the above

You must check and agree to all of the following prior to being approved for an appointment:

Wearing a mask is optional

If you would prefer that the practitioner wear a mask, please let us know

You will cancel or re-schedule if you experience any symptoms of any type of infection and no cancellation fees will be applied

Agree to all of the above

By submitting this form, you confirm that you have answered truthfully and agree to the above terms

Yes

No

I have more questions before we proceed, please contact me

*Brain Recoding, Meditation, NLP, manifesting your dreams, Magnetic Mind Coach Training, overcoming limiting beliefs, find a life coach

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