COVID-19 WELLNESS FORM – MOBILITYSALON.COM COVID-19 WELLNESS FORM - MobilitySalon.com This online form MUST be completed and submitted within 24 hours prior to your appointment time, but no later than the night before your appointment. Name* First Last Email Address* Phone*Appointment Date* Date Format: MM slash DD slash YYYY You should be submitting this form within 24 hours prior to your appointment.Appointment Time* : HH MM AM PM You should be submitting this form within 24 hours prior to your appointment.Do you have a cough?*YesNoDo you have a fever now, or have you had a fever in the past 14 days?*YesNoHave you come in contact with any confirmed COVID-19 positive patients within the last 14 days?*YesNoAre you experiencing unusual shortness of breath or difficulty breathing?*(This is not referring to normal conditions such as asthma.)YesNoAre you experiencing other flu-like symptoms?*YesNoHave you experienced recent loss of taste or smell?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YesNoHave you traveled into New York State from one of the following States within the past 14 days? If yes, please select the State.*NOAlaskaAlabamaArkansasCaliforniaDelawareFloridaGeorgiaGuamIdahoIowaIllinoisIndianaKansasKentuckyLouisianaMarylandMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew MexicoNevadaOhioOklahomaPuerto RicoSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaWest VirginiaWisconsinWyomingDo you have a friend or relative staying or living with you who has traveled into New York State from one of the following States within the past 14 days? If yes, please select the State.*NOAlaskaAlabamaArkansasCaliforniaDelawareFloridaGeorgiaGuamIdahoIowaIllinoisIndianaKansasKentuckyLouisianaMarylandMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew MexicoNevadaOhioOklahomaPuerto RicoSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaWest VirginiaWisconsinWyomingPhoneThis field is for validation purposes and should be left unchanged.