COVID-19 SCREENING FORM
Do you or have you felt hot or feverish in the last 14-21 days
Are you having shortness of breath or other difficulties breathing?
Do you have a cough?
Do you have any flu-like symptoms, gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you in contact with any COVID-19 positve patients?
Are you over the age of 60?
Do you have heart disease, lung disease, diabetes or any auto-immune disorders?
Have you travelled outside of Monroe County in last 14 days?

Beard & Holmen Ltd.

208 Bradford Lane

Waterloo, IL 62298

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