COVID-19 QUESTIONNAIRE
Please answer the following questions:
1. Do you currently (or in the past 14 days) have any of the following?
Fever (100.4° F [38° C] or greater using an oral thermometer)
Shortness of breath (not severe)
Cough
Chills
Repeated shaking with chills
Muscle Pain
Headache
Sore Throat
New loss of taste or smell
2. Have you traveled outside the United State in the last 14 days?
Yes
No
3. Have you had any contact with anyone with COVID-19 in the last 14 days?
Yes
No
4. Are you caring for someone or living with someone who is ill or at high risk for COVID-19?
Yes
No
Name
*
First Name
Last Name
Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
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