COVID-19 Questionairre This relates to the previous 72 hours Name of Parishioner* First Last Date* Date Format: MM slash DD slash YYYY Phone*Please check YES/NO for each symptom listedFever?* Yes No Unknown Shortness of breath, not from existing medical conditions or allergies?* Yes No Unknown New loss of Smell/Taste?* Yes No Unknown Fatigue?* Yes No Unknown New cough (not related to existing condition)?* Yes No Unknown New nasal congestion (not related to seasonal allergies)?* Yes No Unknown Muscle aches/Aches and pains?* Yes No Unknown Sore throat?* Yes No Unknown Diarrhea?* Yes No Unknown Headaches?* Yes No Unknown The following questions relate to the last 14 days.Have you been out of state?* Yes No Have you been asked for self-quarantine?* Yes No Other reasons to believe you may have had an exposure to COVID-19?* Yes No Unknown Have you, or someone you have been in close contact with been diagnosed with COVID-19?* Yes No Unknown Will any children be attending church with you this Sunday?* Yes No How old are the children?If the children are 16 and older, they will also need to answer the questionnaire. If they are under 26, they will continue to worship at home.Are you able to wear a mask to church and keep it on?* Yes No If you cannot wear a mask for service, it is recommended that you stay home to worship for the safety of others.If you have checked YES to any of the above questions, you should continue to worship at home for the next few weeks.