COVID-19 Screening Questionnaire

(Your contact information will only be used if we need to make contact regarding exposure.)

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Please, answer the following questions:

Do you have a fever or felt hot or feverish recently (14-21 days)? *

Yes

No

If yes, when did the fever occur?

Are you having shortness of breath or other difficulties breathing? *

Yes

No

Do you have a cough? *

Yes

No

Any flu-like symptoms, GI upset, headache, or fatigue? (Ex: Chills, repeated shaking with chills, muscle pain, sore throat, diarrhea) *

Yes

No

Have you experienced a recent loss of taste or smell? *

Yes

No

Have you traveled outside of Kansas or to any of the hot spot areas in the state of Kansas in the past 14 days (or will you before your visit to Highland)? *

Yes

No

If yes, when and where did/will you travel?

Have you tested positive for COVID-19 or come in direct contact with someone who did? *

Yes

No

If yes, when?

Signature *

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