COVID-19 Screening Questionnaire FULL NAME:* Phone Number* E-mail* 1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your oral temperature before you answer this question.) Fever (100.4 degrees F or greater) YES NO Cough YES NO Difficulty Breathing YES NO Sore Throat YES NO Loss of Taste / Smell YES NO Chills YES NO Headache or Muscle Ache YES NO Nausea, Diarrhea, Vomiting YES NO 2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? YES NO 3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19 YES NO 4) Have you been tested for COVID-19 and are waiting to receive test results? YES NO 5) Have you had the COVID-19 shots within the last 14 days? YES NO If you answered "YES" to any question, please provide comment on why you said you answered a "yes" on the question. By checking this box, I acknowledge that I have answered the above questions truthfully (check in place of signature.)* I CONSENT Submit
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