Wellness

Please complete the form below prior to the start of your business day.

Name*
First Last
ENGS Email*
Have you felt feverish?
- Yes
- No
Do you have a cough?
- Yes
- No
Do you have a sore throat?
- Yes
- No
Have you been having trouble breathing or shortness of breath?
- Yes
- No
Do you have muscle aches?
- Yes
- No
Have you had a new or unusual headache (e.g., not related to caffeine, diet, or hunger, not related to a history of migraines, clusters, or tension, not typical to the individual)?
- Yes
- No
Have you noticed a new loss of taste or loss of smell?
- Yes
- No
Have you been experiencing chills?
- Yes
- No
Is anyone in your household displaying any symptoms of COVID-19?
- Yes
- No
To the best of your knowledge, have you or anyone in your household come in close contact with anyone who has tested positive for COVID-19?
- Yes
- No
Were you IN OFFICE or OUT OF OFFICE on the date specified above?*
- IN OFFICE
- OUT OF OFFICE
Hidden
I was not in the office on the date specified above.
- True
By checking this box I confirm I have completed the questions accurately and to the best of my knowledge.*
- I Agree

"*" indicates required fields

Name*

First Last

Company*

Phone*

Email*

Comments*

Phone

This field is for validation purposes and should be left unchanged.

Loans made or arranged pursuant to a California Finance Lenders Law license.