Coronavirus Measures Checklist

Coronavirus Measures Checklist
Name
First NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Are you careful about?
Yes I'll be more careful
Cleaning your hand?
Avoiding close contact with others?
Avoiding touching your face, nose, mouth, etc?
Adjusting air conditioning?
Are you experiencing any of the following symptoms?
Yes No Any thoughts?
Cough
Fever
Shortness of breath
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
Any other symptoms?
What is your current temperature?
Steps to be taken to protect others:
- If you're experiencing any of the symptoms above, get medical attention immediately.
- Stay home if you're sick.
- Cover your mouth with a tissue when you cough or sneeze, if you don't have any tissue near, use your elbow to cover and wash immediately.
- Wear a mask if you're sick. If you're not sick, you don't have to wear mask, they should be saved for caregivers.
- Make sure you are always clean and sterilize frequently the places you touch.
- Avoid crowding
Should be Empty:

	Yes	I'll be more careful
Cleaning your hand?
Avoiding close contact with others?
Avoiding touching your face, nose, mouth, etc?
Adjusting air conditioning?

	Yes	No	Any thoughts?
Cough
Fever
Shortness of breath
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face