Tuscola County
COVID-19 Health Screening
Email address *
Name *
Phone Number *
In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness? *
Yes
No
Subjective fever (felt feverish):
New or worsening cough:
Shortness of breath or difficulty breathing:
Loss of smell or taste:
In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness? *
Yes
No
Chills
Headache
Sore throat
Muscle aches
Vomiting
Diarrhea
Fever
DISCLAIMER: This screening tool is subject to change based on the latest information on COVID-19
If you answer YES to any of the symptoms listed in section 1, OR YES to two or more of the symptoms listed in section 2, OR your temperature is 100.4 F or higher, please do not go into work. Self-isolate at home and contact your primary care physician’s office for direction.
You should isolate at home until you are fever free for at least 24 hours, your symptoms are improving, and it
has been at least 10 days since symptoms first appeared or per guidance of your local health department or
healthcare provider.
o If diagnosed as a probable COVID-19 or test positive, call your local health department and make
them aware of your diagnosis or testing status.
In the past 14 days, have you: *
Yes
No
Had close contact with an individual diagnosed with COVID-19?
Have you been told by the health department or your healthcare
provider to self-isolate or self-quarantine?
Have you traveled internationally or taken a cruise?
If you answer YES to either of these questions, please do not go into work. Self-quarantine at home for 14 days. Contact your primary care physician’s office if you have symptoms or have had close contact with an individual for evaluation. If you are given a probable diagnosis or test positive call your local health department to ensure they are aware.
*
Required
A copy of your responses will be emailed to the address you provided.
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