Health Check Form

Name

First Name

Last Name

Email

Phone Number

What is today's date?

In the last 48 hours, have you had a fever, cough, shortness of breath, or other respiratory issues?

In the last 48 hours, have you had diarrhea, fatigue, headache, muscle aches, nausea, sore throat or vomiting?

Have you lost your sense of taste or smell?

Right now do you feel sick in any other way?

In the last 14 days, have you been in close contact with someone that has been sick with Covid-19 or with anyone who has any symptoms consistent with Covid-19?

Thank you for taking the time to answer all of these questions. If you answered YES to any of these questions, please talk to Renee before your participation in a Higher Flow event. <3