COVID Questionnaire

COVID-19 screening questions:

Do you have any new or unexpected symptoms?
• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

If you answered “YES” to any of the above symptoms, please stay home and contact your
healthcare provider

Have you had contact with a confirmed COVID-19 patient?
• If yes: Are you being monitored by the health department?

If you answered “YES” to any of the above questions, please stay home and contact your
healthcare provider. We’ll see you soon.