Ellen Noble, Inner Sanctum: 2020 Client Intake Form

Name *

First

Last

Date *

Date of Birth *

Phone *

Email *

Reason for Visit Today: *

Check All that APPLY:

Do you have a fever or above-normal temperature (>100.4° F)? Take temperature.
Are you experiencing shortness of breath or having trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell or taste?
Do you have a sore throat?
Are you experiencing chills or repeated shaking with chills?
Do you have unexplained muscle pain?
Do you have a headache?
Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Have you traveled more than 100 miles from your home in the last 14 days?

Have you been tested for COVID-19 in the last 14 days? If “no,” you may skip the next question.

YES
NO

If yes, what is the result of the testing? If negative, proceed to next question. If still waiting on results, schedule appointment after results are known.

I agree to notify Ellen Noble (Inner Sanctum) if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand Ellen Noble (Inner Sanctum) has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days. *

AGREE

By checking the box below, I am attesting that the information I have provided is accurate and I give my consent for care. *

AGREE