HEALTH QUESTIONNAIRE

Name

First Name

Last Name

SYMPTOMS OF COVID-19

According to the CDC, symptoms of Covid-19 include but are not limited to: Fever exceeding 100.4 degrees Fahrenheit and/or chills. Shortness of breath and/or difficulty breathing. Cough. Sore throat. Congestion and/or runny nose. Nausea, vomiting and/or diarrhea. Headache. New loss of taste or loss of smell. Fatigue. Muscle and/or body aches. For the latest, up-to-date information on Covid-19, you can visit the CDC's site

I have read the symptoms of Covid-19

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with Covid-19 within the past thirty (30) days.

I affirm that I, as well as all household members, have not tested positive for or been diagnosed with Covid-19 within the past thirty (30) days.

I affirm that I, as well as all household members do not, and have not have any of the symptoms of Covid-19 within the past thirty (30) days.

I, the undersigned Client, warrant that I am competent to contract in my own name. I confirm that I have read this Agreement prior to its execution and I am fully familiar with its contents. This Agreement shall be binding on me and my heirs, legal representatives and assigns.