SCREENING Web Site Full Name of Person Screened * Temperature (Farenheit) * Have you had any of the following symptoms currently believed to be related to Covid-19: * Yes No Loss of taste and/or smell 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 Has anyone in your household been in contact with someone confirmed to have COVID-19 in the last 14 days? * Yes No Have you taken any medication for the purpose of fever or temperature reduction in the last 24 hours? * Yes No Signature *
