Health Precautions Form
Please complete the Health Precautions Form to help us track and promote safe health practices.
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Have you experienced any of the following symptoms in the past 14 days?
*
Fever
Cough
Shortness of breath
Sore throat
Loss of taste or smell
None of the above
Have you traveled internationally in the past 21 days?
*
Yes
No
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Not sure
Are you currently up to date with recommended vaccinations?
*
Yes
No
Prefer not to say
How often do you practice hand hygiene (washing hands or using sanitizer)?
*
Please Select
Always
Often
Sometimes
Rarely
Never
Do you wear a face mask in public indoor spaces?
*
Always
Sometimes
Rarely
Never
Have you attended any large gatherings (over 50 people) in the past 14 days?
*
Yes
No
Please provide any additional health precautions or comments.
Email Address (for follow-up if needed)
example@example.com
Submit
Should be Empty: