Moshiri Team Daily Screening Staff Screening Form Name* First Last Do you have any of the following:*Please check any that apply or NONE OF THE ABOVE . If you check any of these please phone Dr. Maz directly at (314) 616-7156 Fever 100.4 or above Shortness of breath or difficulty breathing (new or worsening)* Cough (new cough or worsening chronic cough) Runny nose Stuffy nose Sore throat Painful swallowing Headache Chills Muscle or joint aches Feeling unwell in general, or new fatigue or severe exhaustion Gastrointestinal symptoms (nausea, vomiting, diarrhea or unexplained loss of appetite) Loss of sense of smell or taste Conjunctivitis, commonly known as pink eye NONE OF THE ABOVE I certify my temperature before coming to the office is:*
