Coronavirus Daily Symptom Log
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name
First Name
Last Name
Age
Email
example@example.com
Phone Number
Please enter a valid phone number.
Please select your current symptoms?
Cough
Sore throat
Vomiting
Diarrhea
Difficulty breathing
Unexpected muscle aches
Loss of taste or smell
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
Other
Have you been around anyone exhibiting these symptoms or has tested positive for COVID-19 within the past 14 days?
Yes
No
What is your current temperature?
Signature
Submit
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