HEALTH QUESTIONNAIRE

These questions are to screen for people who could transmit the virus causing COVID-19. The information will remain confidential and reviewed only by the leader of your group or local clergy. Please fill out this form at least 4 days before you plan to attend a group at Burke UMC. Persons who have 2 or more of the listed symptoms or who have been in contact with anyone experiencing symptoms of COVID-19 in the past 14 days cannot attend at this time.

Health Questionnaire
TRAVEL: Have you traveled away from your regular living area (many members live in neighbording states and commute into Virginia - that does not count as travel to another state) to another state or outside the country in the past 14 days? Please indicate:
SYMPTOMS: Please indicate if you are now experiencing, or have experienced during the past 14 days: Fever, feeling hot, or feverish
Shortness of breath or difficulty breathing
Chills, or repeated shaking with chills
Cough
Flu-like symptoms, diarrhea, intestinal upset, or fatigue
Sore throat
Headache
Muscle Pain
Recent loss of taste or smell
CONTACT: Have you come in contact with someone experiencing symptoms of COVID-19 (identified above) in the past 14 days?
TESTING: I tested positive for COVID-19.
TESTING: I have or had symptoms of COVID-19 and I am waiting for results of COVID-19 testing.
TESTING: If tested for COVID-19, I agree to provide the results of my test to my group leader or clergy.
HEALTH CHANGE: If I develop 2 or more of the common symptoms of COVID-19 (listed above) after attending Burke UMC, I will immediately contact my group leader or clergy and I will avoic contact with others and seek immediate medical attention.
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6200 Burke Centre Parkway Burke, VA  22015

703.250.6100