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6
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1
Name
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First Name
Last Name
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2
Email
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example@example.com
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3
Phone Number
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Area Code
Phone Number
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4
In the past 14 days, I have experienced...
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No
Fever 101°F +
Row 0, Column 0
Row 0, Column 1
Unexplained body aches or pain
Row 1, Column 0
Row 1, Column 1
Coughing
Row 2, Column 0
Row 2, Column 1
Sore throat
Row 3, Column 0
Row 3, Column 1
Shortness of breath
Row 4, Column 0
Row 4, Column 1
Chills with or without body aches
Row 5, Column 0
Row 5, Column 1
Recent loss of sense of smell or taste
Row 6, Column 0
Row 6, Column 1
Unexplained sores on soles of feet
Row 7, Column 0
Row 7, Column 1
Unusual fatigue
Row 8, Column 0
Row 8, Column 1
Non-allergy related runny nose
Row 9, Column 0
Row 9, Column 1
Fever 101°F +
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
Yes
Row 8, Column 0
No
Row 8, Column 1
Yes
Row 9, Column 0
No
Row 9, Column 1
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5
Terms and Conditions
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6
Signature
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