Name *

First Name

Last Name

Date *

MM

DD

YYYY

Cough

Option One

Option Two

Shortness of Breath *

Yes

No

Fever *

Yes

No

Chills *

Yes

No

Muscle Pain *

Yes

No

Headache *

Yes

No

Sore Throat *

Yes

No

Loss of Taste or Smell *

Yes

No

In the past 24 hours have you been in close contact with someone who has tested positive or is suspected of having COVID-19? *

Yes

No

In the past 2 weeks have you been in close contact with someone who has tested positive or is suspected of having COVID-19? *

Yes

No