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Cunningham Chiropractic, P.C. George T. Cunningham, D.C. 210 Old Bridge Street, East Syracuse, NY 13057 www.CunninghamChiropractic.com 3154459941 Fax 3154452073COVID QUESTIONNAIREPatient Name:Date:SelfDeclaration
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Start by providing your personal information such as name, date of birth, and contact information.
02
Answer questions regarding your recent travel history and any potential exposure to COVID-19.
03
Provide information about any symptoms you may be experiencing or if you have been in contact with someone who tested positive for COVID-19.
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Answer any additional questions as required by the specific questionnaire you are filling out.
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Review your answers for accuracy before submitting the completed questionnaire.

Who needs covid questionnaire?

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Individuals who are required to enter certain facilities or attend events that mandate the completion of a COVID-19 questionnaire.
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Healthcare workers who need to track and monitor potential COVID-19 cases among their patients.
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Employers who want to ensure the safety of their employees and customers by screening for COVID-19 symptoms.
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A COVID questionnaire is a set of questions designed to gather information regarding a person's exposure to COVID-19, symptoms, travel history, and vaccination status.
Individuals who have been exposed to COVID-19, are showing symptoms, or are required by certain organizations or governmental agencies to determine COVID-19 status may be required to file a COVID questionnaire.
To fill out a COVID questionnaire, individuals need to answer all questions truthfully, providing information about symptoms, exposure history, and vaccination status as required.
The purpose of a COVID questionnaire is to assess the risk of COVID-19 infection and to facilitate contact tracing, testing, and safe practices to protect public health.
The information that must be reported includes personal identification details, recent travel history, known exposures to COVID-19, symptoms experienced, and vaccination history.
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