COVID19 screening form.
Full Name
*
First Name
Last Name
Have you experienced any of the following symptoms of COVID-19 with the last 48 hours?:
*
No Symptons
Fever or chills
Cough
Shortness of breath or any difficulty breathing
Muscle or body aches
Headaches
New Loss of taste or smell
Sore throat
Congestion or running nose
Nausea or vomiting
Diarrhea
Are you currently awaiting results from a COVID-19 test?
*
Yes
No
Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example, a doctor, nurse, pharmacist, or other) in the past 10 days?
*
Yes
No
Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days?
*
Yes
No
Digital Signature
Date
Should be Empty: