COVID-19 Screening Questionnaire COVID-19 Screening Questionnaire Date* Date Format: MM slash DD slash YYYY Location*Tonganoxie Public LibraryName* First Last Do you currently have any of the following symptoms that cannot be attributed to another health condition?* Fever (100.4 or higher) Chills Muscle or body aches Fatigue Headache Sore Throat Lower respiratory illness (cough, shortness of breath and or difficult breathing) New loss of taste or smell Diarrhea None of the above Within the last 10 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic patients, 48 hours prior to test specimen collection) with: Anyone who is known to have laboratory-confirmed COVID-19? OR Anyone who has any symptoms consistent with COVID-19?**If yes is selected, please continue to self-monitor for 14 days after exposure.* Yes No Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?* Yes No Are you currently waiting on the results of a COVID-19 test?* Yes No Declaration* I declare the answers provided are true and accurate.
