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EAS Wellness Check Form
Submission ID
Status
Status: (Caution)
Status: OK
Date
*
-
Month
-
Day
Year
Date
Please indicate whether you are a client or employee.
*
Client
Employee
Therapy Type
*
In-Home Therapy
Center-Based Therapy
Purpose
*
Checking-In
Checking-Out
Monitoring Symptoms
Check-In Time
*
Hour Minutes
AM
PM
AM/PM Option
Check-Out Time
*
Hour Minutes
AM
PM
AM/PM Option
Temperature
*
Name
*
First Name
Last Name
Please select your nearest location.
*
Please Select
Alabama
Connecticut
Delaware
District of Columbia
Georgia
Idaho
Illinois (Chicago)
Illinois (St. Louis)
Indiana
Karnataka
Maryland
Massachusetts
Michigan
Missouri
New Hampshire
New Jersey
Oregon
Pennsylvania
Queensland
Rhode Island
Tennessee
Victoria
Vermont
Virginia
Washington
West Bengal
Please select your clinician. (Alabama)
*
Please Select
Krishonna Payne
Hope Frantom
Courtney Woodard
Tiffany Lee
Laura Hughes
Cassie Chaparro Maillet
Lauren Cotlin
Frances Tsang
Jelissa Williams
Please select your clinician. (Georgia)
*
Please Select
Shana Fentress
Kayli Pledger
Kacie Meyer
Shonda Smith
Kali Camerio
Quantrell Fortune
Cayla Clark
Blake Garrett
Please select your clinician. (Idaho)
*
Please Select
Amber Young
Sonja Cortopassi
Tereza Hopewell
Please select your clinician. (Chicago, IL)
*
Please Select
Trisha Iannotta-Bieszczad
Michelle Berlisnki
Kat Weiland
Jordan Kaehler
Danyelle Sawyers-Takemasa
Shonda Smith
Kristin Harker
Nico Salemi
Mary Kate Dunne
Jessica Montalvo
Hania Jakszuk
Please select your clinician. (Maryland)
*
Please Select
Kelly Collins
Marcie Ialapi
Soraya Dos Santos
Jessica Doyle
Jennifer Tatanish
Hannah Schroeder
Please select your clinician. (Massachusetts)
*
Please Select
Katie Sheppard
Emma Choi
Julie Janmey
Zoey Pierce
Emily Harn
Dennis Bradley
Kate Marsh
Alicia Jakobcic
Michelle Foran
Please select your clinician. (Michigan)
*
Please Select
Gabby Naula-Quintero
Jordan Meeth
Karoline Kenville
Kelly Baker
Kristine Warchock
Rose Lee
Samantha Wiles
Sheila Hartley
Elise Hester
Jacqueline Green
Shavaughn Young
Kristen Nelson
Please select your clinician. (St. Louis, MO/IL)
*
Please Select
Sophia Howard
Melissa Vesser
Sadiqa Reza
Kristen Azotea
Brooke Bellers
Lori Vitello
Katie Blue
Louie Van Deven
Erin Baker
Please select your clinician. (Oregon/Washington)
*
Please Select
Courtney Zonca
Audrey Roqueza
Emily Hargis
Brigette Spring
Jaclyn Brooks
Christina Seifried
Masha Garanovskaya
Morgan Sparks
Please select your clinician. (Pennsylvania/New Jersey)
*
Please Select
Hannah Syal
Nicole Doyle
Meghan McGovern
Cassie Bodnar
Please select your clinician. (Tennessee)
*
Please Select
Jessica Ventimiglia
Heather Snodgrass
Allison Bancroft
Aubrey Tirado
Rochelle Whitley
Chris Keenan
Jasmine James
Please select your clinician. (Virginia)
*
Please Select
Elizabeth Pfister
Mary Searls
Jessica Miller
Brian White
Meghan Staat
Madison Pitts
Jessica Hofmeyer
Benjamin Leigh
Claire Wingen
Sylvia Kriva
Please select your clinician. (Australia)
*
Please Select
Jayne Franklin
Gaya Shastri
Jenna White
Lewis Yau
Nadhuva Husein
Christy Prawira
Ana Barkaia
Chelsea Meadows
Narissa Wongratana
Have you, or anyone in your home experienced any symptoms in the last 72 hours?
*
Yes
No
Please select any symptoms you or your family have experience in the last 72 hours that were NOT due to a pre-existing medical condition?
*
Fever (Temperature over 100.0 F)
Sweats/Chills
Difficulty Breathing
Constant Dry Cough
Chronic Fatigue
Severe Cold/Flu-like Symptoms
Congestion, Sneezing, or Runny Nose
Unexplained Headaches or Muscle Aches
Diarrhea
Vomiting
Other
Have you or anyone in your home been exposed to someone with Covid-19 in the last 14 days?
*
Yes
No
Maybe
Have you or anyone in your home been exposed to someone showing Covid-19 symptoms in the last 14 days?
*
Yes
No
Maybe
Is anyone in your home currently in quarantine due to Covid-19?
*
Yes
No
Have you, or anyone in your home, traveled domestically, or internationally, within the last 14 days?
*
Yes
No
Submit
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Home
About Us
Our Services
Early Intensive Behavioural Intervention
Occupational Therapy
Speech Pathology
What is Applied Behaviour Analysis
School and Kinder Readiness
Our Locations
Australia
Victoria
Cranbourne Clinic
United States
Alabama
Birmingham
Montgomery
Georgia
Atlanta
Duluth
Idaho
Illinois
Chicago
St. Louis
Maryland
Michigan
Ann Arbor
Detroit
Missouri
Oregon
Portland
Salem
Tennessee
Virginia
India
Karnataka
West Bengal
Latest News
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