COVID-19 Symptom Questionnaire
Your Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you fully vaccinated against COVID-19?
Yes
No
Other
Have you experienced any of the following symptoms in the past 14 days? (Please check all that apply.)
Fever
Cough
Tiredness
Loss of taste or small
Sore throat
Headache
Aches and pain
Diarrhoea
A rash on skin
Red or irritated eyes
Difficulty breathing, shortness of breath
Loss of speech or mobility or confusion
Chest pain
Other
In the last 14 days, have you been in close proximity to anyone who was experiencing the above symptoms?
Yes
No
In the last 14 days, have you traveled abroad or been in contact with someone who traveled abroad?
Yes
No
Date & Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
Submit
Should be Empty: