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» COVID-19 Health Screening Questionnaire
COVID-19 Health Screening Questionnaire
Name
*
Email Address
*
Phone Number
*
Which workshop or screening are you registering for?
*
Have you experienced any of the following symptoms within the last 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
Congestion or runny nose
Nausea or vomiting
Diarrhea
None of the above
Have you tested positive for COVID-19 in the past 14 days?
*
Yes
No
Are you currently awaiting results from a COVID-19 test?
*
Yes
No
Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example: a doctor, nurse, pharmacist, or other) in the past 14 days?
*
Yes
No
Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 14 days?
*
Yes
No
Have you cared for or had close contact with someone who has tested positive for COVID-19 in the past 14 days?
*
Yes
No
Have you recorded a body temperature of 100.4 degrees Fahrenheit or above in the past 14 days?
*
Yes
No
Leave this field blank
