Adult - Wellness Pre Check In (Bloomingdale Church)
Please complete form from your home before coming to the program, preferably at least 30 minutes before the start of the program.
Your Name *
*If your answer YES to any of the questions, please stay home and let your team know.
Do you currently have a temperature 100 degrees or higher? *
Please confirm by taking your temperature.
Have you had a 100 degree fever or higher in the past 24 hours, or taken any symptom reducer? *
Symptom reducer examples (to reduce fever): Tylenol, Ibuprofen, cough suppressant, Imodium
Have you, or anyone living in your home, experienced any of the following symptoms in the past 24 hours: Fever, chills, cough, shortness of breath or difficulty breathing, headache, sore throat, recent loss of taste or smell, nausea, vomiting, or diarrhea? *
Have you, or anyone living in your home, had a close contact++ in the last 14 days with someone with a diagnosis of COVID-19? *
++A "Close Contact" is someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated. Anyone considered a close contact to someone who has been identified as positive for the virus may not attend for 14 calendar days.
Model the 3 W's - Wear a mask, Watch distance, Wash hands
You are a stakeholder in helping us to maintain our wellness standards. Please personally model and help others about wearing a mask that fully covers nose and mouth, social distancing, and frequent hand sanitization.
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