COVID-19 Resident Screening

1. In the last few days, have you experienced

• Cough
• Shortness of breath or difficulty breathing

OR at least 2 of these symptoms not explained by a chronic condition?

• Fever (100.4 degrees or higher)
• Chills
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
• Repeated shaking with chills
• Muscle pain
• Headache
• Sore throat
• New loss of taste or smell

YES NO

2. In the last 14 days, have you had contact with someone with a confirmed diagnosis of COVID-19, or under investigation for COVID-19, or have undiagnosed respiratory symptoms?

YES NO

3. What is your temperature today? (numbers up to the tenth of a degree) i.e.: 98.6-100.3

If you answered YES to any of the above questions or begin to experience symptoms,
please notify the Beacon Hill COVID-19 Hotline at 616-734-9544.

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• • • •

616-245-9179

1919 Boston Street SE
Grand Rapids, MI 49506

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