Name

First

Last

Age

Sex

Birthday

Email Address

Today Temperature;

Do you have any of the following flu like symptoms:

Do you have a chronic medical conditaion such as diabetes,hypertension,cancer,immune compromising disorder?

Yes No

If YES, Please specify:

Do you have anyone living with you who is above 60 years of age?

Yes No

Do you have anyine living with you who us suffering fron low immunity or chronic disease (diabetes, hypertension,cancer,etc.)

Yes No

If YES, Please specify:

Do you have health insurance?

Yes No

Medical Certificate