TODAY'S DATE *

MM

DD

YYYY

CLIENT'S FIRST & LAST NAME *

First Name

Last Name

ARE YOU VACCINATED? *

YES

NO

WHEN DID YOU GET VACCINATED?

MM

DD

YYYY

Have you had a fever in the last 24 hours of 100 Fahrenheit or above? *

YES

NO

DID YOU GET A BOOSTER SHOT? *

YES

NO

WHEN DID YOU GET YOUR BOOSTER SHOT?

MM

DD

YYYY

Do you have now any respiratory or flu symptoms? *

YES

NO

Do you have sore throat? *

YES

NO

Do you have shortness of breath? *

YES

NO

Do you have aches, pains, weakness, fatigue? *

YES

NO