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Graduation 2021 Self-Health Screening Questionnaire

Please review and answer the following questions prior to entering the facility. If the answer is “Yes” to any of the questions, please do not enter the facility. Information regarding signs and symptoms of COVID-19 can be found on the SAMHD website at: https://covid19.sanantonio.gov/What-YOU-Can-Do/Symptoms. For questions regarding symptoms of COVID-19 please contact your healthcare provider.    
Name (Last, First):(Required.)
Address:
Phone number:(Required.)
Name of graduate you are here to see (Last, First):
Have you recently begun experiencing any of the following symptoms in a way that is not normal for you?

 • Cough
 • Shortness of breath
 • Difficulty breathing
 • Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit
 • Loss of taste or smell
 • Headache
 • Chills
 • Sore throat
 • Shaking or exaggerated shivering
 • Significant muscle pain or ache
 • Diarrhea
 • Nausea or vomiting
 • Congestion or runny nose

(Required.)
Within the last 14 days, have you been in contact with someone who has tested positive for COVID - 19, or has shown any of the above symptoms?

(Required.)
Within the last 14 days, have you traveled outside of the United States?

(Required.)
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