COVID-19 Symptom Evaluation

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Please take the time to answer a few questions about symptoms, travel, and contact you’ve had with others. No information will be shared with a third party.

What is your name?

Please enter your email address.

How old are you?

Under 18

Between 18 and 64

65 or older

Have you recently started experiencing any of these symptoms? Check all that apply

Fever or chills

Mild or moderate difficulty breathing

Sustained loss of smell, taste or appetite

Sore throat

Vomiting or diarrhea

Aching throughout the body

None of these

Do any of these apply to you? Select all that apply

Moderate to severe asthma or chronic lung disease

Cancer treatment or medicines causing immune suppression

Inherited immune system deficiencies or HIV

Serious heart conditions, such as heart failure or prior heart attack

Diabetes with complications

Kidney failure that needs dialysis

Cirrhosis of the liver

Extreme obesity

Pregnancy

None of the above

In the last 14 days, have you traveled internationally?

I have traveled internationally

I have not traveled internationally

Clear selection

In the last 14 days, have you been in an area where COVID-19 is widespread? Select all that apply

I live in an area where COVID-19 is widespread

I have visited an area where COVID-19 is widespread

None of the above

I don’t know

In the last 14 days, what is your exposure to others who are known to have COVID‑19?Select all that apply.

I live with someone who has COVID-19

I’ve had close contact with someone who has COVID-19. I was within 6 feet of someone who’s sick, or I was exposed to a cough or sneeze.

I’ve been near someone who has COVID-19. I was at least 6 feet away and was not exposed to a sneeze or a cough.

I’ve had no exposure. I have not been in contact with someone who has COVID-19.

I don’t know

Do you work in a medical facility? This includes a hospital, emergency room, other medical setting, or long-term care facility. Select all that apply

I have worked in a hospital or other facility in the past 14 days. This includes volunteering.

I plan to work in a hospital or other facility in the next 14 days. This includes volunteering

I don’t work or plan to work in a medical facility,

Which state do you live in?

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