Family Covid Pre-screening Questionnaire

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COVID Questionnaire for End of Season Celebration

Names of persons in attendance *

Have you or anyone in your household had any of the following symptoms in the last 14 days: sore throat, , new headache, nausea, diarrhea or vomiting, repeated shaking or chills, muscle pain or body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *

Sore throat

New Headache

Nausea

Diahrrea

Vomiting

Repeated shaking/chills

Muscle Pain or Body Aches

Shortness of Breath

Loss of Smell

Loss of Taste

Required

Have you or anyone in your household been tested for COVID-19? *

Yes

If yes, how recently? & who

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *

Yes

Have you or anyone in your household traveled in the U.S. in the past 14 days? *

Yes

If yes, where did you go and when did you get back?

Is anyone in your household a health care provider or emergency responder? *

Yes

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19 in the past 14 days? *

Yes

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

Yes

If you answered no to all of these questions, or had fewer than two yes responses, please mark YES. If you are a healthcare worker who is tested weekly, please mark YES. If you are not a healthcare worker and have answered yes to two or more questions, please answer NO to this question and we respectfully ask that you do not attend this event. *

Yes

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