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Visitor COVID-19 Questionnaire

Are you experiencing any of these symptoms? (Please focus on new or unexpected symptoms).*
Answer Required
Yes
No
Fever and/or chills
Shortness of breath/difficulty breathing
Cough, congestion, sore throat, and/or runny nose
Fatigue and/or headache
Muscle aches
Nausea, vomiting, and/or diarrhea
New loss of taste and/or smell
Have you had contact with anyone diagnosed with confirmed Coronavirus (COVID-19) in the past 14 days?*
Answer Required

If you answered YES to any of the above questions, PLEASE EMAIL GEANA CHAPP GCHAPP@KOMAREK94.ORG IN THE HEALTH OFFICE FOR FURTHER INSTRUCTIONS

Thank you for completing this COVID-19 questionnaire.