FISD Visitor COVID-19 Screening Questionnaire / Cuestionario de evaluación del visitante COVID-19 del FISD
This form must remain confidential /
Este formulario debe permanecer confidencial
Email address *
Date / Fecha *
MM
/
DD
/
YYYY
Last Name / Apellido *
First Name / Nombre de pila *
Have you recently begun experiencing any of the following in a way that is not normal for you? Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit, Loss of taste or smell, Cough, Difficulty breathing, Shortness of breath, Fatigue, Headache, Chills, Sore Throat, Congestion or runny nose, Shaking or exaggerated shivering, Significant muscle pain or ache, Diarrhea, Nausea or Vomiting? ¿Has comenzado recientemente a experimentar algo de lo siguiente de una manera que no es normal para ti? Sensación de fiebre o una temperatura medida mayor o igual a 100.0 grados Fahrenheit, pérdida del gusto u olfato, tos, dificultad para respirar, falta de aire, fatiga, dolor de cabeza, escalofríos, dolor de garganta, congestión o secreción nasal, temblores o escalofríos exagerados, significativo dolor o dolor muscular, diarrea, náuseas o vómitos? *
Have you had close contact with an individual who is lab-confirmed with COVID-19? ¿Ha tenido contacto cercano con una persona que ha sido confirmada en laboratorio con COVID-19? *
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