Client Pre Appointment Questionnaire Full Name Email Phone Have you experienced any of the following in the past 24 hours? Fever Yes No Fatigue Yes No Cough Yes No Sneezing Yes No Aches & pains Yes No Runny or Stuffy Nose Yes No Sore Throat Yes No Diarrhea Yes No Headache Yes No Shortness of Breath Yes No Have you been in close contact with someone who has exhibited any of these symptoms? Yes No Have you been in contact with anyone who has tested positive for COVID-19? Yes No Send Thank you in advance for your cooperation.
