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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