Health Declaration

Emergency Contact

Health History

Allergies to Medication

Tell me about your eating habits.  What triggers your eating?

What kind of foods do you enjoy?

How often do you cook your own meals?

Which phrases describe you?

Coronavirus Declaration

Do you or anyone in your home currently have coronavirus symptoms (fever/chills, loss of taste or smell, cough, nausea, shortness of breath, difficulty breathing, fatigue, muscle or body aches, sore throat, diarrhea, chest pain, new confusion, difficulty staying awake, blue lips or face)?

Have you or anyone in your home had coronavirus or been tested for it?

I certify that the answers I have provided are complete and accurate.  

Thanks for submitting!