Turkey Creek | COVID Screening

1

Name

First Name

Last Name

2

Phone Number

Area Code

Phone Number

3

Have you been told to quarantine/isolate by a health care provider or the health department within the last two weeks?

YESNO

4

Have you had face-to-face contact for 10 or more minutes with someone who has COVID-19 within the last two weeks?

YESNO

5

Are you feeling ill/ and or experiencing any of the following? Fever (prior to use of fever-reducing medications), Cough, Shortness of breath, New loss of sense of taste/smell, Vomiting or Diarrhea (within the past 24 hours)

YESNO