COVID-19 Patient Screening

Your name *

First Name Last Name
Date *

Month Day Year
Date
Are you presenting with any of the following symptoms? *

Fever Shortness of breath Dry cough Runny nose Sore throat Recent loss of taste or smell Recently in contact with any confirmed COVID-19 positive patients Heart disease, lung disease, diabetes or any auto-immune disorder Travelled in the past 14 days outside the state of Oregon Over 60 years old I am not presenting with any of the above symptoms
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