COVID19 Screening Form
Full Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Date of Submission
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Month
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Day
Year
Date
Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea
Yes
No
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: Anyone who is known to have laboratory-confirmed COVID-19? OR Anyone who has any symptoms consistent with COVID-19?
Yes
No
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
Yes
No
Are you currently waiting on the results of a COVID-19 test?
Yes
No
Have you travelled abroad in the last 1-2 months? Where did you go?
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