Health Questionnaire Regarding Covid-19

Please answer the following questions below:

* Full Name

* What is your current body temperature?

(Fahrenheit)

* Have you had a fever (temperature >99F) or chills in the past 24 hours?

* Are you, a family member, or someone you are in close contact with currently awaiting COVID-19 test results?

* Have you tested for COVID-19 with a positive result in the past 14 days?

* Have you been diagnosed with COVID-19?

* Have you been living with or in close contact with someone with a CONFIRMED diagnosis of COVID-19 in the past 14 days?

* Have you been living with or in close contact with a person undergoing testing for COVID-19 within the past 14 days?

* Have you traveled out of state in the past two weeks?

In the past 24 hours have you experienced any of the following symptoms?

* New cough

* Scratchy throat

* Shortness of breath or difficulty breathing

* Tiredness or fatigue

* Joint and muscle pain (as a flu-like symptom)

* Dry throat

* New sore throat

* Nasal congestion or runny nose

* Change in or loss of taste or smell

* Headache

* Nausea or vomiting

* Sneezing

* Unexplained body aches

* Diarrhea

Greensboro Performing Arts
Cardinal Crossing Shopping Center
2231 Fleming Road
Greensboro NC 27410
336.549.2228
info@greensboroperformingarts.com

NEW SUMMERFIELD LOCATION
7200 Summerfield Road
Summerfield, NC 27358

New Garden Friends School
7101 Pleasant Oaks Road
Greensboro, NC 27410