COVID-19 COVID-19 Daily Symptom Checklist for ACEN Forums and Meetings COVID-19 Daily Symptom Checklist for ACEN Forums and Meetings Step 1 of 4 25% HiddenDate Submitting Form: MM slash DD slash YYYY HiddenACEN Meeting Location* Atlanta Financial Center – 3343 Peachtree Rd NE, Suite 850, Atlanta Lenox Towers – 3390 Peachtree Rd NE, Suite 1400, Atlanta JW Marriott Atlanta Hotel, Buckhead Westin Galleria, Houston, TX Date of ACEN Meeting / Forum:* MM slash DD slash YYYY First Name* Last Name* Email* 1. Are you currently experiencing any of the following symptoms?* Yes No Symptoms • Temperature of 100° Fahrenheit or higher • Chills • Cough • Shortness of breath or difficulty breathing • Fatigue • Muscle or body aches • Headache • New loss of taste or smell • Sore throat • Congestion or runny nose • Nausea or vomiting • Diarrhea – – – Check all symptoms that apply.* Temperature of 100° Fahrenheit or higher Chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea 2. Have you tested positive by an FDA-authorized or FDA-licensed test for COVID-19 in the last fourteen (14) days?** Yes No 3. Have you come in close contact with someone that has tested positive by an FDA-authorized or FDA-licensed test for COVID-19 within the last fourteen (14) days?** Yes No
