COVID Symptom & Exposure Questionnaire

First Name *

Last Name: *

Are you staff or a visitor? *

My temperature today was: *

100.4 degrees or higher

less than 100.4 degrees

Have you had a fever in the last 72 hours? *

Yes

No

Do you currently have any of the following symptoms? *

Cough

Shortness of Breath

Difficulty breathing

Shaking/Chills

Muscle pain

Sore Throat

Headache

Loss of Taste or Smell

Diarrhea

Feeling feverish

NONE of the above

Required

Have you been in contact with anyone who tested positive for COVID-19? *

Yes

No

Maybe