COVID-19 Screening QuestionsPlease complete the following questions prior to arriving for your session. Name * First Name Last Name Date of Service * MM DD YYYY Time of Service * Hour Minute Second AM PM 1. Have you traveled outside of NH, CT, ME, VT, RI or MA in the last 14 days? * No, Proceed To Question #3 Yes* Please Answer Question #2 2. Have you traveled Internationally? No, Proceed to Question #3 Yes, Please Contact Amanda at (603) 801-7352 Prior To Appointment 3. Have you had a fever or chills in the past 24 hours without using fever reducing medicine? No, Proceed to Question #4 Yes, Please Contact Amanda at (603) 801-7352 Prior To Appointment 4. Have you had any UNPROTECTED close prolonged contact with anyone with suspected or confirmed COVID-19 in that last 14 days? Please note that wearing a cloth face mask is NOT considered protection. No, Proceed to Question #5 Yes, Please Contact Amanda at (603) 801-7352 Prior To Appointment 5. Are you having any of the following symptoms? Shortness of breath, Muscle Aches, Cough, Sore Throat, Fatigue, Headache, Nausea, Vomiting, Diarrhea, Nasal Congestion, Runny Nose AND/OR Changes in your sense of taste or smell that is atypical for you. No, Proceed to Question #6 Yes, Please Contact Amanda at (603) 801-7352 Prior To Appointment 6. Have you been fully vaccinated? Fully vaccinated means 14 days post all required vaccinations to complete series. Yes No By Checking this box, I attest that all information on this form is true and accurate. * Thank you!