Pre Covid-19 Vaccine Questionnaire
1. In the past 14 days, have you tested positive for COVID-19? *
2. In the past 14 days, have you been in close contact with anyone who tested positive for COVID-19? *
3. Do you currently has fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea? *
If you answer Yes to any of the questions above you are not qualified to receive the vaccine at this time. Please schedule appointment with the doctor, present yourself to the nearest ER, or dial 911 for medical assistant.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy