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Bearden | COVID Screening
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1
Name
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First Name
Last Name
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2
Phone Number
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Area Code
Phone Number
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3
Have you received both covid-19 vaccinations?
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YES
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4
Have you been told to quarantine/isolate by a health care provider or the health department within the last two weeks?
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5
Have you had face-to-face contact for 15 or more minutes with someone who has COVID-19 within the last two weeks?
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6
Are you feeling ill/ and or experiencing any of the following? Cough, Fever (prior to use of fever-reducing medications), Shortness of breath, New loss of sense of taste/smell, Vomiting, Diarrhea, or Chills (within the past 24 hours)
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