COVID-19 SCREENING

COVID-19 SCREENING
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PLEASE READ EACH QUESTION CAREFULLY

PLEASE CLICK THE ANSWER THAT APPLIES TO YOU
Have you experienced any of the following symptoms in the past 48 hours:
- fever or chills
- cough
- shortness of breath or difficulty breathing
- fatigue
- muscle or body aches
- headache
- new loss of taste or smell
- sore throat or runny nose
- nausea or vomiting
- diarrhea
Have you experienced any of the above symptoms in the past 48 hours?*

YESNO
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?*

YESNO
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?*

YESNO
Are you currently waiting on the results of a COVID-19 test?*

YESNO
Please Sign*

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