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Client Screening -Form Fill

Section One
Q1

Name*

First Name
Q2

Name*

Last Name
Q3

Phone Number*

Phone Number
Q4

Appointment Date*

Date
Q5

Appointment Time*

Hour
Q6

Appointment Time*

Minutes
Q7

Appointment Time*

AM/PM Option
Q8

Have you had a cough?*
Q9

Have you had a fever?*
Q10

Have you had shortness of breath?*
Q11

Have you had any close contact with anyone with these symptoms or anyone who has been diagnosed with Covid-19 in the past 14 days?*
Q12

Date Submitted*

Date