Wellness Center Name* First Last Phone*Where can you be reached right now?HiddenCounty of Residence*If you live out-of-state, please choose “other” at the bottom of the list.AlleganBarryCalhounIoniaKentKalamazooOttawaVan BurenAlconaAlgerAlpenaAntrimArenacBaragaBayBenzieBerrienBranchCassCharlevoixCheboyganChippewaClareClintonCrawfordDeltaDickinsonEatonEmmetGeneseeGladwinGogebicGrand TraverseGratiotHillsdaleHoughtonHuronInghamIoniaIoscoIronIsabellaJacksonKalkaskaKeweenawLakeLapeerLeelanauLenaweeLivingstonLuceMackinacMacombManisteeMarquetteMasonMecostaMenomineeMidlandMissaukeeMonroeMontcalmMontmorencyMuskegonNewaygoOaklandOceanaOgemawOntonagonOsceolaOscodaOtsegoOttawaPresque IsleRoscommonSaginawSt. ClairSt. JosephSanilacSchoolcraftShiawasseeTuscolaWashtenawWayneWexford— OTHER —HiddenOther County of Residence*What is the county and state where you reside? Affiliation*Check all that apply Tribal Citizen Citizen Household Native (non-Citizen) Native Household GLT Staff GLT Staff Household Today's Activity* Functional Fitness Training HIIT Solo Workout HiddenDo you have any of the following symptoms? Do not check if symptom is something you normally deal with.HiddenSymptoms* Fever (over 100.4) Chills/Shakes Muscle Aches Headache Sore Throat Smell/Taste Change Cough Shortness of Breath Difficulty Breathing Nausea/Vomiting Diarrhea –None of the above– HiddenWhat is your temperature?*HiddenContact*Have you had any close contact with a person who is known or suspected to have COVID-19 in the last 14 days? Yes No HiddenVaccination*Have you received 2 doses of the Moderna or Pfizer Covid-19 Vaccine or 1 dose of the Johnson and Johnson COVID-19 Vaccine more than 14 days ago? Yes No HiddenTravel*Have you traveled internationally or domestically in the last 14 days via mass transit including airplane, train or bus? Yes No HiddenVaccination*Have you received 2 doses of the Moderna or Pfizer Covid-19 Vaccine or 1 dose of the Johnson and Johnson COVID-19 Vaccine more than 14 days ago? Yes No NameThis field is for validation purposes and should be left unchanged.
