Wellness Check India

Please indicate whether you are a client or employee.*

Therapy Type*

Purpose*

Date*

Check-In Time

:

Check-Out Time*

:

First Name*

Last Name*

Temperature*

Have you, or anyone in your home experienced any of these symptoms in the past 72 hours.*

Other Symptoms

If other, please explain.

Are any of these symptoms due to a pre-existing or unrelated medical condition?*

Have you or anyone in your home been exposed to someone with Coronavirus (COVID-19)?*

Have you or anyone in your home been exposed to someone showing Coronavirus (COVID-19) symptoms?*

If exposed, has it been addressed and resolved?*

How many days passed after exposure and work release?*

Have you or anyone in your home traveled domestically, or internationally, within the past 14 days?*