Health Screening Questionnaire Form

* Have you experienced cough, shortness of breath/difficulty breathing, or two or more of the following symptoms in the past 48-hours:

• Fever or chills?
• Muscle or body aches?
• New loss of taste or smell?
• Congestion or runny nose?
• Diarrhea?

• Fatigue?
• Headache?
• Sore throat?
• Nausea or vomiting?

* Within the past 5-days, have you tested positive for COVID-19, or been in close physical contact (6-feet or closer for a total of 15-minutes) with anyone who has tested positive for COVID-19?

* Are you currently 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?