COVID-19 Screening Questionnaire
If your answers to these questions change at any point, please contact Mercer Medicine at (478) 301-7425.
First Name*
Last Name*
Mercer Email*
Mercer Employee ID#*
Phone Number*
Select any of the following symptoms you may be experiencing:
Fever or chills
Cough
Shortness of breath or difficulty breathing
Muscle or body aches
Headache
Recent loss of taste or smell
Sore Throat
Congestion or runny nose
Nausea, vomiting, or diarrhea
Have you been contacted by a health care provider or public health representative to inform you that you were exposed to someone with COVID-19?*
Choose One
Yes
No
If so, when were you contacted?*
Have you been tested for COVID-19?*
Choose One
Yes
No
If yes, what was the result?*
Choose One
Positive
Negative
When were you tested?*
Additional Comments
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