Health Self-Assessment Health Self-Assessment Form Please fill out one per family group Name PhoneName PhoneName PhoneName PhoneHave you had any symptoms of COVID-19 in the past 14 days such as fever, cough, shortness of breah, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat?Have you had any symptoms of COVID-19 in the past 14 days such as fever, cough, shortness of breah, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat? Yes No Have you had any symptoms of COVID-19 in the past 14 days such as fever, cough, shortness of breah, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat? Yes No Have you had any symptoms of COVID-19 in the past 14 days such as fever, cough, shortness of breah, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat? Yes No Have you had any symptoms of COVID-19 in the past 14 days such as fever, cough, shortness of breah, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat? Yes No Have you tested positive for COVID-19 in the past 14 days?Have you tested positive for COVID-19 in the past 14 days? Yes No Have you tested positive for COVID-19 in the past 14 days? Yes No Have you tested positive for COVID-19 in the past 14 days? Yes No Have you tested positive for COVID-19 in the past 14 days? Yes No Have you been in close contact with someone with COVID-19 symptoms in the past 14 days?Have you been in close contact with someone with COVID-19 symptoms in the past 14 days? Yes No Have you been in close contact with someone with COVID-19 symptoms in the past 14 days? Yes No Have you been in close contact with someone with COVID-19 symptoms in the past 14 days? Yes No Have you been in close contact with someone with COVID-19 symptoms in the past 14 days? Yes No If you or anyone else in your family group answer “yes” to any of the questions, we ask that you do not come into church today.We are asking for contact information to allow for contact tracing only and will not be used for any other purposes.CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
