PILI COVID-19 Wellness Form

Name*

First Name

Last Name

Phone*

Email*

Do you currently have a cough?*

Yes No

Do you have a fever now and/or have you had a fever in the past 14-21 days?*

Yes No

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?*

Yes No

Are you experiencing shortness of breath or difficulty breathing?*

Yes No

Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*

Yes No

Have you experienced a recent loss of taste and/or smell?*

Yes No

Have you traveled in the past 14 days to any other regions affected by COVID-19?*

Yes No

Where have you traveled?

I understand that I will be required to wear a mask to enter and while in PILI’s offices if I am not fully vaccinated.*

Please check to confirm.

I will contact PILI (mbergmann@pili.org) before arriving at its offices if any of my answers to the above questions should change.*

Please check to confirm.

Date of your expected visit to PILI’s offices:*