COVID-19 Screening

1

Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

3

Phone Number* This field is required.

Area Code

Phone Number

4

Email

6

Screening Questions

7

Do you have heart disease, lung disease, kidney disease, diabetes, asthma, or any auto-immune disorder?

YESNO

8

Do you have a fever or have you felt hot or feverish recently (14-21 days)?

YESNO

9

Have you experienced shortness of breath or had trouble breathing?

YESNO

10

Do you have a cough?

YESNO

11

Do you have a runny nose?

YESNO

12

Do you have a sore throat?

YESNO

13

Are you experiencing flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

YESNO

14

Have you experienced a recent loss of taste or smell?

YESNO

15

Have you traveled anywhere by air, bus, or train within the past 14 days?

YESNO

16

Have you been in contact with anyone who has tested positive for COVID-19?

YESNO

17

If yes, what date were you last in contact with a person who tested positive?

Date

18

Have you been tested COVID-19?

YESNO

19

If yes, what date were you tested?

Date

20

Did you test positive for COVID-19?

YESNO

21

When did you receive results (whether negative or positive)?

Date

22

What date was the onset of your symptoms?

Date

23

What date were you cleared of COVID-19?

Date

24

By clicking SUBMIT, you acknowledge that your answers that you provided are true and accurate to the best of your knowledge.