Self-Reported Symptoms Questionnaire Form
Please complete this Self-Reported Symptoms Questionnaire Form to provide a snapshot of your current symptoms. This form is for informational purposes only and does not collect sensitive personal or financial information.
Full Name
*
First Name
Last Name
Date of Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which symptoms are you currently experiencing?
*
Fever or chills
Cough
Shortness of breath
Fatigue
Sore throat
Headache
Other
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the severity of your symptoms?
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Have your symptoms changed in the last 24 hours?
*
Improved
No change
Worsened
Are you currently taking any medications for your symptoms?
*
Yes
No
Please specify any additional symptoms or notes.
Submit
Should be Empty: