COVID-19 Health Screening

Instructions: The purpose of this screening is to comply with safety guidelines in order to protect CBPS clients, visitors, and staff, loved ones, and our community. Everyone planning to visit CBPS (including staff and clients) or to attend an in-person CBPS appointment are required to complete this screening prior to each appointment. When answering the following questions, "close contact" refers to contact such as living together, working together, riding in a car together, or spending time indoors together in a private or public place without masks and/or without 6 feet of physical distance. If it is necessary to bring anyone to the office with you (such as a child or adult family member), you are required to review these questions with that person and to submit separate answers for all persons who might accompany you to the office.

  1. Vulnerability: Are you or anyone with whom you have close contact vulnerable to severe illness from COVID-19 due to age, health, or other known risk factor? YesNo
  2. Symptoms: In the past 14 days, have you or a close contact had fever, cough, shortness of breath, difficulty breathing, chills, fatigue, muscle or body aches, headache, sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting, diarrhea, or other possible flu-like or COVID-19 symptoms? YesNo
  3. Exposure: Have you or a close contact been advised to self-quarantine or been exposed to someone with a possible or confirmed case of COVID-19 in the past 14 days?
  4. Activities: Do you have a higher risk of exposure to COVID-19 due to employment or other activities (as do frontline workers), or in the past 14 days, have you had close contact with anyone who does? YesNo
  5. Travel: Have you or a close contact traveled out-of-state or internationally in the past 14 days? YesNo
  6. Distancing: Have you or a close contact attended a gathering in the past 14 days where social distancing guidelines were not followed? YesNoIf you answered "Yes" to any of the above questions, please finish the screening and submit it, but do not visit the office or attend an in-person appointment without explicit written/emailed permission from our office. Prepare for a telehealth appointment instead. If you are unsure how to answer or if you have questions, please call us at 410-604-0226. If you are not able to reach us, type your questions below and click Submit to send them to your clinician.
  7. Notes: Add any notes, details, or explanation here:
  8. Agreement: Do you and anyone you wish to bring to the office agree to follow all CBPS COVID-19 mitigation policies and related staff instructions? YesNo
  9. Certification: Do you certify that you have answered all of the above questions truthfully and openly to the best of your knowledge and the knowledge of everyone you wish to bring to the office with you? YesNo