Wellness Form Lawrenceville Name First Last Date Date Format: MM slash DD slash YYYY Do you have a cough?YesNoDo you have a fever now or have you in the past 14-21 days?YesNoHave you come in contact with any confirmed COVID-19 positive patients in the last 14 days?YesNoAre you experiencing shortness of breath or difficulty breathing?YesNoAre you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?YesNoAre you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?YesNoAre you over the age of 60?YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?YesNo
