COVID-19 Safety Screening
MPB Group
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Client's Name: *
Today's Date: *
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1) Have you or anyone in your household had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *
Required
2) Have you or anyone in your household/close proximity tested positive for COVID-19? If so, what date? What were the follow up precautions taken: (i.e. 14 day quarantine, tested yourself as a result?) *
4) Have you or anyone in your household traveled outside of the Country or on a cruise ship in the last 14 days? *
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