Name *

First Name

Last Name

Do you have a fever, or have you felt feverish recently? *

Yes

No

Do you have a cough? *

Yes

No

Are you having shortness of breath or any difficulty breathing? *

Yes

No

Do you have chills or repeated shaking with chills? *

Yes

No

Do you have any muscle pain? *

Yes

No

Do you have any recent onset of headache or sore throat? *

Yes

No

Do you have any other flu-like symptoms? *

Yes

No

Do you have any recent loss of taste or smell? *

Yes

No

Have you experienced any recent GI upset or diarrhea? *

Yes

No

Are you in contact with anyone who has been confirmed to be COVID-19 positive? *

Yes

No

Have you traveled in the past 14 days to any regions affected by COVID-19? *

Yes

No

Have you Been tested for COVID-19? If yes, what was the result? *

Yes

No

Have you been diagnosed with COVID-19? If yes, when? *

Yes

No