COVID-19 Health-Screening Form

1. In the last 14 days, have you experienced any symptoms of COVID-19? Including:
  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea
  • Headache
  • Sore throat,
  • New loss of taste or smell
2. In the last 14 days, have you tested positive for COVID-19?
3. In the last 14 days, have you knowingly been in close or proximate contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?