Mr.D's Ultimate Fitness Screening

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Your health and well-being is always our number one priority. Please complete this brief wellness screen prior to leaving your home or before entering the facility. We appreciate your cooperation in keeping our facility and community healthy!

Full Name *

Address *

Phone Number (No spaces or dashes) *

Have you personally tested positive for COVID in the past 14 days or are you awaiting results from a COVID test? *

Yes

Do you live with or have you come in contact with anyone who has tested positive for COVID in the past 14 days? *

Yes

Have you travelled internationally or to any of the following states in the past 2 weeks: Alaska, Alabama, Arkansas, Arizona, California, Delaware, Florida, Georgia, Iowa, Idaho, Indiana, Kansas, Louisiana, Maryland, Missouri, Mississippi, Montana, North Carolina, North Dakota, Nebraska, New Mexico, Nevada, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin? *

Yes

Have you experienced any of the following symptoms in the past 14 days, or are you currently experiencing any of the following: Fever, Chills, Shortness of breath, Loss of smell or taste, Cough, Sore throat *

Yes

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms