Covid Wellness Form - Innovative Counseling Partners

Name

First Last

Phone

Email

Do you have a cough?

Do you have a fever now or have you in the past 14-21 days?

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?

Are you experiencing shortness of breath or difficulty breathing?

Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

Have you experienced loss of taste or smell?

Are you over the age of 60?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)

Comments

This field is for validation purposes and should be left unchanged.