Tolk Wellness COVID-19 Screening Form
At Tolk Wellness Center, nothing is more important than the safety and well-bring of our patients and staff. Thank you for taking the time to answer these short questions as we work tirelessly to protect our community from COVID-19.

If we feel that you may be at risk for spreading a potential COVID-19 infection or are in the High Risk category (immunocompromised, diabetic, history of heart disease, high blood pressure, respiratory issue, over 60 years old, etc.), we may ask that you remain at home and self-isolate.

Finally, as many confirmed cases are asymptomatic, we kindly urge EVERYONE to routinely wash their hands for 20 seconds, cover coughs and sneezes and above all, stay at home as often as possible.
First Name *
Your answer
Last Name *
Your answer
Phone *
Your answer
Email
Your answer
Have you or a family member experienced any flu or cold like symptoms in the past 2 weeks (fever, cough, body ache, fatigue, etc.)? If yes, please describe.
Your answer
Have you traveled internationally or to any US state highly impacted by COVID-19 in the last two weeks (China, Italy, France, New York, Washington, Florida, etc.)?
Your answer
Have you been in close proximity with anyone that may be at risk for a COVID-19 infection?
Your answer
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