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COVID QUESTIONNAIRE
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* Indicates required question
Email
*
Your email
First and last name
*
Your answer
Fever of 100.4°F within the last 48 hours.
*
YES
NO
Have you had close contact with a person who has tested positive for COVID-19 within the previous 14 days?
*
YES
NO
If Yes above please explain. Give details as to the contact.
Your answer
Have you or a member of your household tested positive for COVID-19 in the past 10 days?
*
Yes
No
Have you been tested for COVID-19 and are awaiting test results?
*
Yes
No
I verify that the above information is true.
*
YES
NO
Temp
*
Your answer
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