Please answer Yes or NO to the below Questions:

_{In the past 7 days have you or any household member to the best of your knowledge been exposed to someone with a confirmed diagnosis of Covid-19?}

_{In the past 7 days have you or any household member had any of one of the following symptoms: ?}

• _{Shortness of breath or difficulty breathing}
• _Cough
• _{Fever 100.4 or higher}
• _Fatigue
• _{Muscle or body aches}
• _Headache
• _{New loss of taste or smell}
• _{Sore throat}
• _{Congestion or runny nose}
• _{Nausea or vomiting}
• _Diarrhea
• _RAsh

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If you answered "YES" to any of these questions please notify a staffer immediately prior to your appointment as it may be necessary to have your appointment reviewed prior to entry and possibly rescheduled. 617-566-9856