(530) 662-9161 info@achwoodland.com

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COVID-19

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Pre-COVID Visitation Questionnaire

Complete this questionnaire 24-hours before your visitation. Must be completed before you arrive.

Visitor:*
- 1
- 2
Resident's Name:*
First Last
Relationship to Resident:*
Your Email:*
Your Phone:*
Have you previously tested positive for COVID? If yes, when?*
Did you receive the COVID vaccine? If yes, when did/will you receive your second dose?*
Are you or anyone in your household showing any signs or symptoms of COVID?*
- No signs or symptoms of COVID
- Fever >100 or subjective fever
- Loss of sense of taste or smell
- Cough
- Shortness of breath
- Fatigue
- Muscle or body ache
- Headache
- Congestion or runny nose
- Sore throat
- Nausea, Vomiting, Diarrhea
Have you or anyone in your house had any exposure to someone with a confirmed case of COVID in the last 14 days?*
Do you agree to all of the below questions? Check all of the questions to show you agree with them.*
- Being screened for COVID signs and symptoms upon entry to the facility?
- Receiving a POC COVID test before visitation begins (if applicable)?
- Have a maximum of 2 visitors per visit?
- Wearing a face mask/N95 for the entirety of your visit?
- Staying 6 feet apart during your entire visit (unless all parties have been fully vaccinated)?
- Not bring anything to the facility that can't be easily decontaminated?
- Having a staff member monitor your visit?
- Any breaking of infection prevention protocol, while you are here, will result in your visit being terminated immediately and may exclude you from visiting in the future?
- Notify the facility if you or anyone in your household starts showing signs or symptoms of COVID 14 days after your visit?
- Answering no to any of the above questions are grounds to cancel visitation.
Today's Date:*
MM slash DD slash YYYY
Name of person completing the form?*
First Last
This will count as your legal signature of confirmation.
Email
This field is for validation purposes and should be left unchanged.

Contact Us

Address

Alderson
Convalescent Hospital

124 Walnut Street
Woodland, CA 95695

Phone

(530) 662-9161

Fax
(530) 662-9208

Toll-Free
877-378-8299

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Email

info@achwoodland.com

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