Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:
Shortness of Breath OR Difficulty Breathing
New Loss of Taste OR Smell
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?
Should be Empty: