Name *

First Name

Last Name

Date of Service *

Date of in-person service

MM

DD

YYYY

DX *

Have you ever been diagnosed with COVID-19? Or, are you currently waiting to be tested or waiting for test results to determine if you have/had COVID-19?

Yes

No

Contact *

In the past 2 weeks, have you been in close contact (within 6 feet) of someone who is confirmed of having, is being evaluated for, or suspected of having COVID-19?

Yes

No

Self-Isolation *

In the last 2 weeks, have you been instructed to restrict any activity or recommended to self-isolate by a health care provider due to COVID-19?

Yes

No

Fever *

In the past 2 weeks have you experienced any fevers at or above 100 degrees F?

Yes

No

Unsure

Medications *

In the past 2 weeks have you taken Tylenol, Advil, or other fever-reducing medications?

Yes

No

Chills *

In the past 2 weeks have you experienced any body chills?

Yes

No

Cough *

In the last 2 weeks have you experienced any cough?

Yes

No

SOB *

In the past 2 weeks have you experienced any shortness of breath?

Yes

No

Difficult breathing *

In the past 2 weeks have you experienced any difficulty or pain with breathing?

Yes

No

Sore Throat *

In the past 2 weeks, have you experienced a sore throat?

Yes

No

Muscle Aches *

In the last 2 weeks, have you experienced any muscle aches?

Yes

No

Headaches *

In the past 2 weeks, have you experienced any headaches?

Yes

No

Loss of Smell/Taste *

In the last 2 weeks, have you experienced any loss of smell or taste?

Yes

No

Mask *

Do you agree to wear a mask, face shield, or other face-covering when within 10 feet of other individuals during your in-person course?

Yes

No