MPAT S2 - Health Questionnaire
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What is your name? *
Are you sick or have you felt any symptoms of illness in the past 72 hours including: cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, fatigue, congestion or runny nose, diarrhea, nausea or vomiting? *
Have you been in close contacts with someone who is sick or has felt any of the above symptoms of illness in the past 72 hours? *
Have you been exposed to someone positively diagnosed with COVID-19 or who has not been tested but has been told by a doctor that they probably have COVID-19 in the last 14 days?   *
Have you been in close contacts with someone who has been exposed to someone who tested positive for COVID-19 or someone who has not been tested but has been told by a doctor that they probably have COVID-19 in the last 14 days? *
Have you traveled outside of the United States in the last 14 days? *
Have you been in close contacts with someone who has traveled outside of the United States in the last 14 days? *
Do you agree to wash your hands frequently? *
Are you currently under isolation or quarantine orders? *
Temperature Check (UPON CHECK IN, RECORD YOUR TEMPERATURE HERE THEN SUBMIT) *
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