Outdoor Worship Screening Form

First Name *

Last Name *

Do you have fever or have you felt hot or feverish recently? (14 - 21 days) *

Yes

No

Are you having shortness of breath or other difficulties breathing? *

Yes

No

Do you have a cough? *

Yes

No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes

No

Have you experienced recent loss of taste or smell? *

Yes

No

Are you in contact with any confirmed COVID-19 positive patients? *

Yes

No