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Chiropractic and High Intensity
Laser Care Center
Naperville, Wheaton and Suburban Chicago

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Patient Screening Form

In an effort to provide a safe environment of healthcare for you, other patients, families and our staff, please complete our COVID-19 screening form prior to your office visit.

First Name

Last Name

Email

Within the past two weeks, have you or anyone in your household experienced any of the following?

Difficulty breathing or shortness of breath

Fever over 100 degrees

Coughing

Chills

Sudden change in taste or smell

Any other flu-like symptoms such as muscle ache or fatigue

None of the above

Have you been in contact with anyone tested positive with COVID-19?

Yes

No

Have you traveled to a designated two week quarantine state according to the Illinois Emergency Travel Order?

Yes

No

Initials

Date

I declare that the info I’ve provided is accurate & complete.

Thanks for submitting!

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