Health Screener Check-in District Hall Boston Health Screener + Contact Tracing Form Please complete the following before working out of our space today. Name First Last Email*used for contact tracing Have you experienced any of the following symptoms in the past 24 hours?* Fever New persistent cough or sore throat New shortness of breath Unusual fatigue New muscle aches Unexplained loss of taste or smell Unusual headache Nausea / Vomiting Diarrhea None of the above Has any health authority asked you to self quarantine in the past 14 days?*YesNoHave you had prolonged, close contact with someone diagnosed with COVID-19 or been notified that you may have been exposed to it?*Yes, I haveNo, I have notHave you traveled outside of New England within the last 14 days?YesNo
