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Covid-19

Client Wellness Questionnaire

Client Wellness Questionnaire

If you would rather download the form to print and fill out, download it here.

Please fill out this form to the best of your ability and click submit at the bottom.

Your Name (required)

Your Email Address (required)

Home Phone

Mobile Phone

Do you have any of the following Symptoms

Fever of 100.4 degrees Fahrenheit or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaOther (please describe below)

If other symptoms (above), please describe:

1) Have you been in contact with anyone with COVID-19?
YesNo

2) Have you been practicing social distancing (6ft apart), wearing a mask, washing hands, etc
YesNo

3) Have you traveled outside of the DMV?
YesNo

4) Has anyone visited you at your home or have you visited anyone at their home?
YesNo

If #4 is "Yes":

When has someone visited your home?

Briefly describe how many people and how often?

5) Have you attended one or more social or other gatherings in excess of 10 people?
YesNo

If #5 is yes, were you:
InsideOutdoorsBoth

6) Do you employ a caregiver or housekeeper?
YesNo

7) Are you able to enter and exit a vehicle with little or no assistance?
YesNo

8) Are you able to walk on your own with little or no assistance?
YesNo

9) Have you developed any new medical conditions since March 15, 2020?
YesNo

Any Further Questions? Contact Us.

Contact Us

Happy Clients

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3204 Blueford Road, Kensington, MD 20895 | Phone: (301) 332-1900

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Covid-19