COVID-19 Check List - Client Check In

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Attend SEEI
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About

covid-19 checklist - check-in procedure

please complete the covid-19 symptom & exposure checklist below

* Indicates required field

Name *

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Last

Date of Birth *

Today's Date *

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Have you been exposed to COVID-19, exhibit any COVID-19 related symptoms, or have traveled out of the country in the last 14 days? *

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By signing your digital name below, you are attesting to this content being true in nature regarding COVID-19 exposure and/or the exhibition of any current or past symptoms. *

Are you exhibiting any of the following current or past symptoms? *

Fever Cough Coughing of Blood/ Spitting of Blood Congested Nose Phlegm Shortness of Breath/Respiratory Difficulties Headache Sore Throat Jaw/Facial Pain General Muscle or Joint Pain Fatigue/Exhaustion Concentration Difficulties Loss of Smell Loss of Taste Nausea, Vomiting Diarrhea

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