Select YES or NO for each of the follow: I have had... *
Yes
No
A new fever (38.0°C or 100.4° F or higher) or a sense of having a fever?
A new cough that cannot be attributed to another health condition?
New shortness of breath or difficulty breathing that cannot be attributed to another health condition?
New chills that cannot be attributed to another health condition?
A new sore throat that cannot be attributed to another health condition?
New muscle aches (myalgia) that cannot be attributed to another health condition or specific activity (such as physical exercise)?
A new loss of taste or smell?
Contact with someone in the past 14 days with suspected or confirmed COVID-19?
A positive COVID-19 test result myself from which I have not yet been medically cleared.?
Yes
No
A new fever (38.0°C or 100.4° F or higher) or a sense of having a fever?
A new cough that cannot be attributed to another health condition?
New shortness of breath or difficulty breathing that cannot be attributed to another health condition?
New chills that cannot be attributed to another health condition?
A new sore throat that cannot be attributed to another health condition?
New muscle aches (myalgia) that cannot be attributed to another health condition or specific activity (such as physical exercise)?
A new loss of taste or smell?
Contact with someone in the past 14 days with suspected or confirmed COVID-19?
A positive COVID-19 test result myself from which I have not yet been medically cleared.?
Please select the approximate time you took your temperature today *
Choose
Before 5:00 am
5:15 am
5:30 am
5:45 am
6:00 am
6:15 am
6:30 am
6:45 am
7:00 am
7:15 am
7:30 am
7:45 am
Please select the temperature you recorded in degrees Celsius. A temperature at 38 degrees Celsius or above is defined as a fever. *
Choose
Below 36.0 ° C (96.8°F)
36.6°C (96.8°F)
36.1°C (96.9°F)
36.2°C (97.1°F)
36.3°C (97.3°F)
36.4°C (97.5° F)
36.5°C (97.7°F)
36.6°C (97.9° F)
36.7° C (98.1° F)
36.8°C (98.2°F)
36.9° C (98.4°F)
37.0° C (98.6° F)
37.1° C (98.8° F)
37.2° C (99.0° F)
37.3° C (99.1° F)
37.4° C (99.3° F)
37.5° C (99.5° F)
37.6° C (99.7° F)
37.7° C (100.0° F)
37.8° C (100.2° F)
37.9° C (100.3° F)
38.0° C (100.4° F)
Above 38° C (100.4° F)
Please select one of the following options, and thank you for completing your at-home health screening. By working together, we can minimize our health risks! *
If you have any questions or concerns about this form, please type them in the box below. Thank you!
Your answer
A copy of your responses will be emailed to the address you provided.