COVID-19 Health Questionnaire

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Rebelution // September 19th, 2021 at Coffee Butler Amphitheater

First Name *

Last Name *

Email *

Phone Number *

Are you currently experiencing or have you experienced in the past 14 days any of the following? Please only answer "yes" if symptoms are new or worsening, and not associated with pre-existing medical conditions for which you are under a medical practitioner's care. Check all that apply. If none, please check NONE: * *

NONE

Fever (100.4 or greater)

Cough

Shortness of breath or difficulty breathing

Sore throat

New loss of taste or smell

Chills

Head or muscle aches

Nausea, diarrhea, vomiting

Required

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

Yes

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? * *

Yes

Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? * *

Yes

Yes, but I have since tested negative and been medically cleared by my doctor

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