CLIENT HEALTH QUESTIONNAIRE
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Name
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Format: (000) 000-0000.
Prior to the start of my service, I confirm that:
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I do not have a pending COVID-19 test.
I have not been diagnosed with or cared for anyone with COVID-19 in the past 2 weeks.
I have not shown signs or been in close contact with anyone that is exhibiting these symptoms: COUGH, FEVER/CHILLS, SHORTNESS OF BREATH, DIFFICULTY BREATHING, SORE THROAT, LOSS OF TASTE OR SMELL, FATIGUE, HEADACHE, CONGESTION, OR RUNNY NOSE, NAUSEA OR VOMITING OR DIARRHEA
I have not traveled outside of my immediate daily routine for the past two weeks.
If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Madison Ave Electrology.
I will follow all posted office rules to keep myself, Madison Ave Electrology, and those around me safe.
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