Wellness Form

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Date

Patients Full Name

Date of Birth

Person filling out form (if different than the patient)

Symptoms

None

Cough

Fever

Shortness of Breath

Sore Throat

Headache

Body Aches

Diarrhea

Nausea/vomiting

Abdominal Pain

Loss of taste/smell

Other

Emergency Warning Signs (call 911 immediately)

Trouble Breathing

Persistent pain or pressure in chest

New confusion or inability to arouse

Bluish lips or face

Travel History

Have you traveled out of the state in the past 14 days?

Have you had any family or friends who have traveled out of state in the past 14 days?

None

Contact info

Have you had any close contact within the last 14 days with a person confirmed with Covid-19 or being tested for Covid-19?

Have you had any close contact within the last 14 days with a person who has had any of the above symptoms?

Do you live in a facility where facility-based spread of Covid-19 is occurring?

None

Note

Thanks for submitting!

Home
training
In-Home Services
Apply/Refer a Patient
Insurance
Locations
Volunteer
Careers
Concierge
Blog
About Us
Privacy Practices
More

Centralized Intake Fax:
1.888.334.3050

LOCATIONS:

UTAH

Ogden • Salt Lake City • Springville

St. George • Tooele • Vernal • Wasatch Back

IDAHO

Fruitland • Eagle/Meridian

COLORADO

Denver • Loveland

NEVADA

Las Vegas

ARIZONA

Gilbert • Phoenix

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