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Roastery Visitor Health Questionaire

A brief questionnaire used by the staff of a coffee shop to assist in the identification of individuals at risk for infection and to minimize the spread of disease transmission.

Page 1

Please answer the following questions to help us ensure the safety of all our visitors and staff.

Email*

Full Name*

Date of Visit*

Select date

Phone Number*

Address*

City*

Description:Ensure the safety of your coffee shop visitors with this Roastery Visitor Health Questionnaire. This brief questionnaire helps identify individuals at risk for infection and minimize the spread of disease transmission.

Protect your coffee shop visitors and staff with this Roastery Visitor Health Questionnaire. As the world continues to battle the COVID-19 pandemic, it's important to take precautions to ensure the safety of everyone who enters your establishment. This questionnaire helps identify individuals who may be at risk for infection and allows you to take necessary measures to prevent the spread of disease transmission. By asking simple questions about symptoms, recent travel, and exposure to others who may be infected, you can quickly determine if a visitor should be allowed entry or asked to leave. Use this Roastery Visitor Health Questionnaire to prioritize the health and safety of your customers and staff.

What is your full name?*

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What is your date of birth?*

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Patient Name*

Date of Birth*

Address*

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What challenges did you face...*

What was the date of your last therapy session?*

Select date

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Patient Name*

Date of Birth*

Address*

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Date of Birth*

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Address*

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What is your date of birth?*

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What is your gender?*

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Date of Birth*

Phone Number*

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Introduction*

Consent to Telehealth Services*

I understand that telehealth services involve the use of electronic communications to enable healthcare providers to diagnose and treat me from a remote location.

I understand that telehealth services may not be as complete as face-to-face services.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth services at any time.

I understand that there are potential risks associated with the use of telehealth services, including but not limited to technical difficulties, unauthorized access, and interruptions in service.

Patient Information*

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