Name First Last Age Sex Birthday Email Address Phone Today Temperature; Do you have any of the following flu like symptoms: — Select — Fever Cough Sore Throat Runny Nose Shortness of Breath None 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 Powered by weForms Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on LinkedIn (Opens in new window)Like this:Like Loading... Related
