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COVID-19 Questionnaire

"*" indicates required fields

Were fever-reducing meds administered?*
Do you have any of the following symptoms? (cough, shortness of breath, new loss of taste or smell)*
Do you have any of the following symptoms? (At least 2: chills, shivers, muscle aches, sore throat, nausea/vomiting, diarrhea, fatigue, congestion, runny nose)*
Were you in close contact (within 6 ft.> 10 min) with anyone diagnosed with COVID 19 in the past 14 days?*
Do you have any household members with symptoms of COVID-19 or who have been diagnosed with COVID-19?*
Have you traveled recently to an area of high community transmission?*
This field is for validation purposes and should be left unchanged.