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COVID-19 Screening Form
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Fever - Temperature above 98.6
*
MM
/
DD
/
YYYY
Fever within last few days
*
Yes
No
Required
Fever - Temp and Day it started
Your answer
Fatigue
*
Yes
NO
Required
Fatigue - please describe and how long (if you answered yes)
Your answer
Dry Cough (not Allergies)
*
Yes
NO
Required
Are you having trouble breathing? Or shortness of Breath? (not regular asthma)
*
Yes
NO
Required
If yes, for how long?
Your answer
Are you having digestive issues, diarrhea, or vomiting?
*
Yes
NO
Required
If so, for how long?
Your answer
Headache
*
Yes
NO
Required
Headaches
Your answer
Muscle pain
*
Yes
NO
Required
Have you been around anyone who has been sick within the last 14 days?
*
Your answer
Muscle Pain - Please describe, chills, location, etc
Your answer
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