COVID-19 Pre-Screening Survey

Home » Covid-19 » COVID-19 Pre-Screening Survey

Updated 8/29/22

You’ll receive an automated email 36 hours prior to your appointment which prompts you to complete the brief survey below.

Read about my updated procedures and precautions here. I welcome you to contact me with any questions!


In the last two weeks, have you …

1. … had contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?*

– Yes

– No

If yes, please contact me at (971) 341-9546 or betsygordon.LAC@gmail.com. I may choose to reschedule your appointment but you won’t be charged a fee.

2. … experienced any of the following symptoms? (* – not related to a pre-existing condition)*

– New cough*

– New shortness of breath*

– Difficulty breathing

– New fever, or feeling feverish

– New chills, or repeated shaking with chills

– New fatigue*

– New body aches or muscle pain not caused by a specific activity such as exercise

– New diarrhea*

– New nasal congestion*

– New sore throat*

– New loss of taste or smell

– I have not experienced any of these symptoms.

If you select present symptoms, please contact me at (971) 341-9546 or betsygordon.LAC@gmail.com. I may choose to reschedule your appointment but you won’t be charged a fee.

3. Are you fully vaccinated against COVID-19?

– Yes

– No

Thank you!

Home • About • Services • Blog • Contact

My acupuncture clinic is centrally located on NE Broadway Street in Northeast Portland, easily reachable from North, SW, and SE Portland. You’ll find easy neighborhood parking.