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Pocket Pa Example Covid 19 Salon Template -Form Fill

Section One
Q1

Full Name*

First Name
Q2

Full Name*

Last Name
Q3

Phone Number*

Phone Number
Q4

Address*

Street Address
Q5

Address*

Street Address Line 2
Q6

Address*

City
Q7

Address*

County / State
Q8

Address*

Post / Zip Code
Q9

E-mail*
Q10

Date of Birth

Date
Q11

Have you felt unwell in the last two weeks?
Q12

Do you have a fever (>37.5)?
Q13

Do you have a new, persistent cough?
Q14

Do you have a sore throat?
Q15

Have you lost your sense of smell or taste?
Q16

Have you been in contact with somebody who has any of these symptoms?
Q17

Have you travelled to an area at high risk of COVID-19, nationally or internationally?
Q18

Do you work in a hospital / care home or healthcare facility?
Q19

Have you been diagnosed with COVID-19?
Q20

Do you live in a household with somebody who has been diagnosed with COVID 19 or has symptoms ?
Q21

Please enter the following information*
Q22

Please enter any other information you think we should know.
Q23

Signature