Covid-19 Questionaire

Eastside Church of Christ Garland, TX

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Coronavirus Screening Questionaire

* Indicates required field

Name *

First

Last

1. Cough? *

Yes No N/A

2. Shortness of breath or difficulty breathing? *

Yes No N/A

3. Chills? *

Yes No N/A

4. Repeated shaking with chills? *

Yes No N/A

5. Muscle pain? *

Yes No N/A

6. Headache? *

Yes No N/A

7. Sore throat? *

Yes No N/A

8. Loss of taste or smell *

Yes No N/A

9. Diarrhea? *

Yes No N/A

10. Feeling feverish or measured temperature of greater that 99.6° F? *

Yes No N/A

11. Have you been in close contact with a person who has tested positive (lab confirmed) to have Novel Coronavirus? *

Yes No N/A

12. Have you tested positive for the Coronavirus? *

Yes No N/A

13. Have you been cleared by the Health Department of you tested positive for the Coronavirus? *

Yes No N/A

14. Have you had a follow up negative test? *

Yes No N/A

15. Have you traveled outside of Texas within the last 14 days? *

Yes No N/A

16. Have you spoken to your doctor about any of your symptoms or travel? *

Yes No N/A

If any member is presenting with any symptom(s) upon arrival to worship service as stated above, he or she will be assessed by medical team, and asked by leadership team to attend alternative worship service.

This will be expected and not optional

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