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Temple Sinai Wellness Check
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* Indicates required question
Name
*
Your answer
Have you or anyone in your household come in close contact with a person diagnosed Covid-19 in the last 7 days?
*
Yes
No
Have you or anyone in your household traveled out of the state of Florida in the last 7 days?
*
Yes
No
Have you or anyone in your household had:
*
Yes
No
cough/shortness of breath or difficulty breathing
chills
muscle pain
headache
sore throat
new loss of taste or smell
Yes
No
cough/shortness of breath or difficulty breathing
chills
muscle pain
headache
sore throat
new loss of taste or smell
Temperature
*
Below 100.4
Above 100.4
Notes
Your answer
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