Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Have you traveled outside of the United States in the last 14 days?

Yes

In the las 14 days, have you been in close contact with a suspected or confirmed case of COVID-19 or tested positive yourself?

Yes

In the last 24 hours, have you experience any of the following in a way not normal to you?

Symptoms:
Feeling feverish or a measured temperature of 100 degrees or above?, Loss of taste or smell, Cough, Difficulty Breathing, Shortness of Breath, Fatigue, Headache, Chills, Sore Throat, Congestion or Runny Nose, Shaking or Exaggerated Shivering, Significant Muscle Pain or Ache, Diarrea, Nausea or Vomiting.

Select an answer:

Yes

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!