Covid Check List

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Covid Check List

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* Indicates required question

First Name *

Your answer

Last Name *

Your answer

Are you running a temperature? *

Yes

No

Do you have a cough? *

Yes

No

Do you have a Sore Throat? *

Yes

No

Do you have shortness of breath? *

Yes

No

Have you bee in contact or cared for some one with covid recently? *

Yes

No

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