symptom report


If you have filled out a headshot form or submitted a business inquiry for an in-person service, you must also complete the following survey the day before your shoot. Please answer all fields honestly and as accurately as possible to protect the safety and health of both parties. If you have any questions, feel free to reach us at 

Please provide the name of the client who will be present on the day of the shoot.

If you responded "YES" to the previous question, please provide the day on which your test was administered and the testing method, if possible (nasal/nasopharyngeal swab, oral/oropharyngeal swab, or antibody test). If you answered, "NO", leave blank. If you have a test scheduled before the day your shoot, please let us know the date of your test.

1. Do you have a fever or have you felt hot or feverish recently (past 14-21 days)?

2. Are you having shortness of breath or other difficulties breathing?

3. Do you have a cough? Or had a cough recently?

4. Any other flu-like symptoms, syuch as gastrointestinal upset, headache, or fatigue?

5. Have you experienced a loss of taste or smell?

6. Have you been in contact with any confirmed COVID-19 positive individuals? 

7. Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

8. Have you traveled in the past 14 days to any COVID-19 hotspots where cases have been significantly increasing (especially Rhode Island, Florida, California, or Texas)?

By clicking submit, you certify that you have answered all of the above questions honestly, accurately, and to the best of your knowledge.

© 2020 Ken Yotsukura Photography

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