COVID-19 Triage Questionnaire Form
Complete this questionnaire to help us assess your COVID-19 risk and recommend next steps.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any of the following symptoms in the past 7 days?
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Loss of taste or smell
Sore throat
None of the above
When did your symptoms begin?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?
*
Yes
No
Not sure
Have you traveled outside your city or state in the last 14 days?
Yes
No
Are you currently experiencing any of the following severe symptoms?
*
Difficulty breathing
Persistent pain or pressure in the chest
New confusion
Inability to wake or stay awake
None of the above
Do you have any of the following pre-existing conditions?
Diabetes
Heart disease
Chronic lung disease
None of the above
What is your current temperature (if measured)?
Please describe any other symptoms or concerns you would like to share.
Submit
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