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?
YESNO
4
Have you had face-to-face contact for 10 or more minutes with someone who has COVID-19?
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
Should be Empty: