• Client Health Questionnaire Form

• Date
• Name*
• Email
• Phone

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• Within the last 48 hours, have you had any of the following symptoms?* Select Cough Chills Diarrhea Fever Rash Runny Nose Sore Throat Vomiting
• In the past five days, have you been in close contact with anyone with symptoms of COVID, flu, pneumonia, measles or any other contagious illness?*

  Yes
  No
  Unsure
  
• Have you traveled outside the country within the last 14 days.?*

  Yes
  No
  
• If necessary, will you wear a mask during this appointment?*

  Yes
  No
  
• 
  
• Signature