COVID-19 SCREENING FORM

Do you or have you had any of the following symptoms or signs? Check all that apply:*
- Fever
- Cough
- Shortness of breath
- No signs or symptoms
Have you traveled outside of Panola county in the last 14 days?*
- Yes
- No
In the past 14 days did you have close contact with someone who is suspect or COVID positive?*
- Yes
- No
Name*
First Last
Phone
Signature
Date*
MM slash DD slash YYYY

Golden Eye Associates