BASKET CREEK MISSIONARY BAPTIST CHURCH
7289 CAPPS FERRY ROAD
DOUGLASVILLE, GA 30135
March 15, 2021
Self- Health Screening
Regarding your personal health, please answer the following questions to the best of your ability:
Are you currently experiencing, or have you experienced within the past 7 days any of the following symptoms?
| Fever (Temp greater than or equal to 100.4 F) |
[] |
Yes |
[] |
No |
| Chills with shaking or teeth chattering |
[] |
Yes |
[] |
No |
| Sore throat |
[] |
Yes |
[] |
No |
| Frequent cough |
[] |
Yes |
[] |
No |
| Shortness of breath at rest |
[] |
Yes |
[] |
No |
| Pain or Tightness in your chest |
[] |
Yes |
[] |
No |
| Flu-like symptoms |
[] |
Yes |
[] |
No |
| Muscle pain (non-exercise related) |
[] |
Yes |
[] |
No |
| Loss of ability to taste or smell |
[] |
Yes |
[] |
No |
Are you well, but a member of your household is sick at home with bronchitis-like or cold symptoms?
[] Yes [] No
Are you or a member of your household awaiting COVID-19 test results, or have you been told to self-isolate?
[] Yes [] No
*If you answered yes to any of the above questions, PLEASE stay home and join us on our Zoom platform.
*All will be screened prior to entering church for service.
