Severe Acute Respiratory Symptoms (SARS)
Pre-Screening Questionnaire
(Check WHO) http://www.who.int/csr/sars/en/ for SARS Travel
Recommendations Summary Chart Updated Daily

1. In the past 10 days, have you been in an area with SARS? Yes ___ No ___
   If yes, where have you been? _____________________
   
2. If yes, do you have any of the following symptoms: Fever, Cough, Difficulty Breathing, or Shortness of Breath? (Please circle the symptoms you have)
   
3. In the past 10 days, have you had close contact with any person who has been diagnosed with SARS? (Close contact is defined as caring for or living with someone with SARS, or having direct contact with infectious material such as respiratory secretions from a person who has SARS.)
   Yes ___ No ___
   
4. Do you have medical health insurance coverage for the entire duration of your stay Hawai‘i?
   Yes ___ No ___
   
   

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