Covid 19 Screening | shearserenity

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I have not experienced any of the following:• Fever • New onset of cough • Worsening chronic cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decrease of loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches (myalgias) • Nausea/vomiting, diarrhea, abdominal pain • Pink eye (conjunctivitis) • Runny nose or nasal congestion without other known cause

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

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

Thank you, provided you checked no to all of the questions we will see you at your scheduled time. When you arrive please text your service provider and we will text you when it is safe to come in. Paula:271-3534 Terra:276-6845 Rozi:275-5691