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Covid Questionnaire 

Today's date: April 22, 2021

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you currently experiencing a fever (100.4 + or chills*?*
No
Yes
Are you experiencing a cough?*
No
Yes
Have you travelled outside the state of WA in the last 5 days?*
No
Yes
Are you currently experiencing shortness of breath or difficulty breathing?*
No
Yes
Are you currently experiencing fatigue?*
No
Yes
Are you currently experiencing muscle or body aches?*
No
Yes
Are you currently experiencing a headache?*
No
Yes
Are you currently experiencing new loss of taste or smell?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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