Covid Symptom Checker 2021

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Name *

Email address *

Phone number *

Are you currently diagnosed with or believe you may have COVID-19? *

Yes

Have you had any of these symptoms of COVID-19 in the past ten (10) days?

High temperature (fever or chills)? *

Yes

A new continuous cough? *

Yes

A new unexplained shortness of breath? *

Yes

A new loss of your sense of smell or taste? *

Yes

New, unexplained muscle pain or body aches? *

Yes

New vomiting or diarrhea? *

Yes

Have you been in contact with a COVID-19 confirmed or suspect case in the previous 10 days? *

Yes

If you have answered 'YES' to any of these questions, you should stay home and inform your manager or medical practitioner. You should follow local current Public Health guidance. CDC Guidelines require any person diagnosed with COVID-19 to self-isolate for 10 days after onset of symptoms or from the day of testing positive and to go at least 24 hours fever free without the use of fever-reducing medications.

By checking the below box, I attest that all questions were answered honestly to the best of my ability.

I Understand

Have you been vaccinated? *

Yes

Temperature

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms