Christ Temple Apostolic Faith Assembly COVID-19 Wellness Survey
Person's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Today's Date
-
Month
-
Day
Year
Date
Email
example@example.com
Have you been exposed to someone who has been diagnosed with COVID-19 in the last 14 days?
Yes
No
Have you recently experienced a new cough?
Yes
No
Are you experiencing any of the following symptoms? Please check the appropriate box.
Cough
Fever
Loss of taste or smell
Shortness of breath
Sore Throat
None
Have you received your Covid-19 vaccine? (optional)
Yes
No
To prevent the spread of the Covid-19 Virus and to help protect others, I agree to follow the Christ Temple Apostolic Faith Assembly Guidelines as given by the Medical Staff. I will take responsibility for my answers and old Christ Temple Apostolic Faith Assembly harmless.
Yes
No
Full Name
First Name
Last Name
Signature
Questions or Comments
Submit
Should be Empty: