Health Assessment - Ampell Barbershop

Date/Time

Name*

First Last

Is your temperature over 100°F?*

No
Yes

Have you had any COVID-19 symptoms in the last 14 days?*

No
Yes

Symptoms include but are not limited to: cough, shortness of breath, difficulty breathing, fever, chills, muscle pain, sore throat, or new loss of taste or smell?

Have you or anyone you were in close contact with tested positive for COVID-19 in the past 14 days?*

No
Yes

Have you had close contact with a confirmed or suspected case of COVID-19 in the past 14 days?*

No
Yes