Mr.D's Ultimate Fitness Screening
Your health and well-being is always our number one priority. Please complete this brief wellness screen prior to leaving your home or before entering the facility. We appreciate your cooperation in keeping our facility and community healthy!
Full Name *
Address *
Phone Number (No spaces or dashes) *
Have you personally tested positive for COVID in the past 14 days or are you awaiting results from a COVID test? *
Do you live with or have you come in contact with anyone who has tested positive for COVID in the past 14 days? *
Have you travelled internationally or to any of the following states in the past 2 weeks: Alaska, Alabama, Arkansas, Arizona, California, Delaware, Florida, Georgia, Iowa, Idaho, Indiana, Kansas, Louisiana, Maryland, Missouri, Mississippi, Montana, North Carolina, North Dakota, Nebraska, New Mexico, Nevada, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin? *
Have you experienced any of the following symptoms in the past 14 days, or are you currently experiencing any of the following: Fever, Chills, Shortness of breath, Loss of smell or taste, Cough, Sore throat *
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