Screening Form for In-Person Mediation Participants * All fields are requiredName* First Last Date of Scheduled Mediation* MM slash DD slash YYYY 1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. a. Fever or chills* Yes No b. Difficulty breathing or shortness of breath* Yes No c. Cough* Yes No d. Sore throat, trouble swallowing* Yes No e. Runny nose/stuffy nose or nasal congestion* Yes No f. Decrease or loss of smell or taste* Yes No g. Nausea, vomiting, diarrhea, abdominal pain* Yes No h. Not feeling well, extreme tiredness, sore muscles* Yes No 2. Have you tested positive for COVID-19 or had close contact with a confirmed or probable case of COVID-19 in the past 10 days?3. Have you had close contact with a confirmed or probable case of COVID-19?* Yes No Δ
