Covid questionnaire
Name
First Name
Last Name
Temp
Date
-
Month
-
Day
Year
Date
Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:
Yes
No
Fever
Cough
Shortness of Breath OR Difficulty Breathing
Chills
New Loss of Taste OR Smell
Muscle Pain
Sore Throat
Extreme Fatigue
Have You traveled internationally, to any areas where COVID is widespread or been on a cruise ship in the last 14 days?
Have You OR A Member of Your Household had close contact with Or cared for Someone Diagnosed With COVID-19 in the last 14 days?
Have You OR A Member of Your Household had close contact with OR cared For Someone With A Presumptive Positive Case Of COVID-19 in the last 14 days?
Have You or A Member of Your Household been asked OR Required to Quarantine based on contact with a person who has a Confirmed OR Presumptive Positive COVID-19 Test Result?
Submit
Should be Empty: