COVID-19 Patient Screening

Your name*

First NameLast Name
Date*

MonthDayYear
Date
Are you presenting with any of the following symptoms?*

FeverShortness of breathDry coughRunny noseSore throatRecent loss of taste or smellRecently in contact with any confirmed COVID-19 positive patientsHeart disease, lung disease, diabetes or any auto-immune disorderTravelled in the past 14 days outside the state of OregonOver 60 years oldI am not presenting with any of the above symptoms
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