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Health Questionnaire Regarding Covid-19
Please answer the following questions below:
*
Full Name
*
What is your current body temperature?
(Fahrenheit)
*
Have you had a fever (temperature >99F) or chills in the past 24 hours?
Yes
No
*
Are you, a family member, or someone you are in close contact with currently awaiting COVID-19 test results?
Yes
No
*
Have you tested for COVID-19 with a positive result in the past 14 days?
Yes
No
*
Have you been diagnosed with COVID-19?
Yes
No
*
Have you been living with or in close contact with someone with a CONFIRMED diagnosis of COVID-19 in the past 14 days?
Yes
No
*
Have you been living with or in close contact with a person undergoing testing for COVID-19 within the past 14 days?
Yes
No
*
Have you traveled out of state in the past two weeks?
Yes
No
In the past 24 hours have you experienced any of the following symptoms?
*
New cough
Yes
No
*
Scratchy throat
Yes
No
*
Shortness of breath or difficulty breathing
Yes
No
*
Tiredness or fatigue
Yes
No
*
Joint and muscle pain (as a flu-like symptom)
Yes
No
*
Dry throat
Yes
No
*
New sore throat
Yes
No
*
Nasal congestion or runny nose
Yes
No
*
Change in or loss of taste or smell
Yes
No
*
Headache
Yes
No
*
Nausea or vomiting
Yes
No
*
Sneezing
Yes
No
*
Unexplained body aches
Yes
No
*
Diarrhea
Yes
No
Submit