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XII Health Screening Form
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Have you recently been in contact with anyone that has tested positive for COVID-19?
*
Yes
No
Do you have a new or worsening cough or shortening of breath/difficulty breathing?
*
Yes
No
Do you currently have a fever or have had one in the past 72 hours? (greater than 100 degrees Fahrenheit)
*
Yes
No
Do you have 2 or more of the following: chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste, smell, diarrhea?
*
Yes
No
By coming to Twelve, you are attesting that you confidently answered “NO” to ALL of the above questions and have a very low risk of carrying or spreading COVID-19. If you answered “YES” to ANY of the above questions, please contact your Carson Robertson at 512-970-6739.
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