COVID-19 Screening Questionnaire

(Your contact information will only be used if we need to make contact regarding exposure.)
Please, answer the following questions: 
Do you have a fever or felt hot or feverish recently (14-21 days)? *
Are you having shortness of breath or other difficulties breathing? *
Do you have a cough? *
Any flu-like symptoms, GI upset, headache, or fatigue? (Ex: Chills, repeated shaking with chills, muscle pain, sore throat, diarrhea) *
Have you experienced a recent loss of taste or smell? *
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)? *
Have you tested positive for COVID-19 or come in direct contact with someone who did? *
Signature *