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Coronavirus
Self-Assessment Form
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Name
*
First Name
Middle Name
Last Name
Date of birth
*
/
Month
/
Day
Year
Date
Personal Email
Have you been in close contact with a confirmed case of coronavirus with the last 14 days?
*
Yes
No
Are you currently experiencing or have you experienced within the last 14 days; shortness of breath, fever, cough or cold symptoms?
*
Yes
No
Please specify details of the symptoms
Have you been in a Hospital, Nursing home or Inpatient Rehab facility within the past 2 weeks?
*
Yes
No
Are you on Dialysis?
Yes
No
Emergency Contact Name
Emergency Contact Phone
-
Area Code
Phone Number
By submitting, I hereby confirm that the information I have given above is true.
*
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