Client Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

I am vaccinated *

Yes

No

SYMPTOMS: Have you or anyone in your household experienced any of the following symptoms in the last 21 days? *

Select all that apply

Fever over 100°F

Cough

Chills

Sore throat

Body aches

Shortness of breath

Loss of smell

None

IN THE LAST 21 DAYS: Have you or anyone in your household been tested for COVID-19? *

Plan to meet by telehealth only if you had positive COVID results in the last 21 days or you are awaiting test results.

Yes, and I am awaiting test results

Yes, and results were negative

Yes, and the results were positive

No

PLEASE SELECT ALL THAT APPLY *

Plan to meet by telehealth only if you check any of the following boxes

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the last 30 days?

Have you or anyone in your household traveled within or outside of the U.S. in the last 21 days?

Have you or anyone in your household traveled on a cruise ship in the last 21 days?

Are you or anyone in your household a health care provider or emergency responder?

Have you or anyone in your household cared for an individual who is in quarantine or has tested positive for COVID-19 in the last 21 days?

Have you been in close proximity to any individual who tested positive for COVID-19 in the last 21 days?

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?

NONE OF THE ABOVE

I agree that I have answered all of the above questions to the best of my knowledge.

By checking this, you are eSigning this form.