TMG Covid-19 Pre-trip Guide Screening

Name*
First Last
Have you received a Covid-19 Vaccine?
- Yes
- No
- I have had the first vaccine and awaiting the second
Have you recently started experiencing any of these symptoms?*
- Fever (100.4f/38c or higher)or chills
- Mild or moderate difficulty breathing
- New or worsening cough that you cannot attribute to another health conditions
- Loss of smell, taste or appetite
- Sore throat
- Vomiting or Diarrhea
- Aching throughout the body
- None of the above
Select all that apply
Do any of these apply to you?*
- Moderate to severe asthma or chronic lung disease
- Cancer treatments or medications that suppress the immune system
- Immune deficiency disorders or disease
- Diabetes with complications
- Kidney condition that requires dialysis
- Liver disease or Cirrhosis of the liver
- Are you pregnant
- None of the above
Please select all that apply
In the last 14 days, what is your exposure to others who are known to have COVID‑19?*
- I live with someone who has Covid-19
- I've had close contact with someone who has Covid-19 (Within 6 ft, exposed to a sneeze or cough))
- I have been near someone with Covid-19 (Within 6 feet but not exposed to a sneeze of cough)
- I have had no known exposure
- I don't know
Select the one that applies
Have you been diagnosed with Covid-19 in the last 30 days"*
What date were you directed that you were no longer contagious?
MM slash DD slash YYYY
Have you ever been tested for the ACTIVE Covid-19 virus?*
What were the results?
Have you ever been tested for Covid-19 antibodies?*
What were the results

TMG Covid-19 Pre-trip Guide Screening

TMG Tetons Covid-19 Pre-trip Guide Screening

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