SCREENING QUESTIONS

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My Boutique

Home
About
Services & Rates
- Packages & Purchases
Documents
Contact
Marketing Help
My Boutique

Screening Questions

Please complete the following screening questions prior to each appointment.

Today's Date

Please enter your First and Last Name:*

Please enter your Email Address*

What is a good contact number for you?*

Please select your scheduled appointment date*

Have you been tested for Covid-19?*

If you answered yes to being tested for Covid-10, when was your test?

What were the results of your Covid-19 test?*

*you do not have to be tested to receive services.

Have you traveled outside of the state of Louisiana in the past 2 weeks.*

If you answered "YES" to traveling, where did you travel to?

Please check off the following symptoms you have felt in the past 1-2 days:

FeverChillsCoughSore ThroatDiarrhea, digestive upsetNasal, sinus congestionLoss of sense of taste or smellFatigueShortness of breathSudden onset of muscle soreness (not related to a specific activity)Rash or skin lesions (especially on the feet)

List any new discomfort with exertion or exercise. If none, list "NONE".

Is there anything else you would like me to know?

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