Health Questionnaire

Novel Coronavirus (COVID 19) Health Screening Questionnaire

Please complete and submit form prior to arriving. All information provided will remain confidential. Any participant who does not complete the form will not be permitted to attend.

* Indicates required field

Name *

First

Last

Date ( Ex. 1-11-20 ) *

Are you awaiting results for a COV-19 test? *

In the past 14 days, have you ( or someone living with you ) been in contact with someone who has recently returned from a trip out of the country or has traveled by plane ( all destinations )? *

In the past few hours, have you ( or anyone living with you ) experienced any flu-like symptoms: unusual cough, fever ( which reaches or exceeds 100.4F ), difficulty breathing, sore throat and/or sudden loss of smell and taste? *

Within the past 14 days, have you been in close contact ( within 6' ) with someone who has been diagnosed with COVID-19 or is awaiting a result of a COVID-19 test? *

Did you take you temperature this morning? *

Was you temperature 100.4F or higher? *

Submit

​Novel Coronavirus (COVID 19) Health Screening Questionnaire

Novel Coronavirus (COVID 19) Health Screening Questionnaire