Complete Each Screening Question by Answering Yes or No:
1. Are you sick today or experiencing any of the following symptoms: fever, cough, shortness of
breath/difficulty breathing, chills, muscle pain, sore throat, or new loss of taste or smell?
NO
2. Have you had fever or felt like you had a fever at anytime during the past 10 days?
YES
NO
3. During the past 10 days, have you experienced any of the following: cough, shortness of
breath/difficulty breathing, chills, muscle pain, sore throat, or new loss of taste or smell?
4. If you answered yes to either of the questions above, has it been more than 72 hours since the
last fever, cough, or symptoms? Date of last symptom(s)__________________
5. Have you had close contact with a person who has a confirmed case of COVID-19 disease?
Or have you had close contact with a person while they were ill, and their healthcare provider
is working to determine if they have COVID-19 within the last 14 days?
Name: _____________________________________________
Date & Time:________________________________________
