COVID-19 Screener Survey – Hindu Temple of Central Arkansas Little Rock

Name *

First

Last *

Last

In the last 14 days, have you been in direct contact with anyone tested positive with COVID-19? *

Yes

No

Have you been advised to self-quarantine in the last 14 days? *

Yes

No

Do you have a new onset cough? *

Yes

No

Do you have a sore throat? *

Yes

No

Do you have shortness of breath? *

Yes

No

Have you had a fever greater than 100.4°F or chills in the last 24 hours? *

Yes

No

Do you have new onset muscle ache, not explained by exercise or activity? *

Yes

No

Do you have loss of taste or smell? *

Yes

No

Have you been tested positive for COVID-19 in last 30 days? *

Yes

No

Comments or Additional Information

Phone *