Medical History
Full Name
*
First Name
Last Name
Are you double vaccinated
Yes
No
Are you experiencing or have you experienced any of the following symptoms in the last 14 days:
*
Fever and /or chills
New onset of cough or worsening chronic cough
Shortness of breath or difficulty breathing
Decrease or loss of taste or smell
unexplained fatigue/lethargy/malaise/muscle aches
Nausea, vomiting or diarrhea
1
Have you or someone in your household tested positive for Covid-19 in the past 10 days or have been told to self isolate
*
Yes
No
Have you or someone in your household been exposed to someone awaiting Covid 19 test results? Or are you awaiting Covid-19 test result
*
Yes
No
Have you or someone in your household travelled outside the country in the last 14 days
*
Yes
No
Type a question
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Sabrina
Sydney
Rachel
Cat
Christine
Tracy
Staff Signature
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