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COVID-19 Screening
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20
Questions
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HIPAA
Compliance
1
Do you have any flu-like symptoms?
*
This field is required.
YES
NO
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2
Do you have a fever or above normal temperature?
*
This field is required.
YES
NO
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3
Have you experienced shortness of breath or had trouble breathing?
*
This field is required.
YES
NO
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4
Do you have a cough?
*
This field is required.
YES
NO
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5
Do you have a runny nose?
*
This field is required.
YES
NO
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6
Have you recently lost or had a reduction in your sense of smell or taste?
*
This field is required.
YES
NO
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7
Do you have a sore throat?
*
This field is required.
YES
NO
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8
Do you have chills?
*
This field is required.
YES
NO
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9
Do you have repeated shaking with chills?
*
This field is required.
YES
NO
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10
Do you have muscle pain?
*
This field is required.
YES
NO
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11
Do you have a headache?
*
This field is required.
YES
NO
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12
Have you been in contact with someone who tested positive for COVID-19?
*
This field is required.
YES
NO
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13
Have you been tested for COVID-19 and are awaiting results?
*
This field is required.
YES
NO
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14
Have you traveled outside Texas in the past 14 days?
*
This field is required.
YES
NO
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15
Where?
*
This field is required.
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16
Have you been on an airplane or cruise in the past 14 days?
*
This field is required.
YES
NO
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17
Have you been in contact with someone with flu like symptoms in the past 14 days?
*
This field is required.
YES
NO
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18
Name
*
This field is required.
First Name
Last Name
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19
Email
example@example.com
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20
Signature
*
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Clear
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