Screening Questionaire

screening

* Indicates required field

Name *

First

Last

Email *

Have you been in contact with anyone that has been diagnosed or is being monitored by the CDC for COVID-19 in the last 30 days? *

Yes No

Traveled out of the country in the last 30 days? *

Yes No

Have you traveled on a cruise ship in the last 30 days? *

Yes No

Are you / they currently experiencing any of the following symptons?

Fever (greater than 100.4 degrees Fahrenheit *

Yes No

Severe Headache *

Yes No

Muscle Pain/Weakness *

Yes No

Diarrhea/Vomiting/Abdominal Pain *

Yes No

Respiratory Symptoms/ Shortness of Breath *

Yes No

Rash/Skin Irritation *

Yes No

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