Covid 19 Screening Questions

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Email *

Option 1

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What is your name? *

Do you have a cough? *

Yes

Do you have a fever now or have you in the past 14-21 days? *

Yes

Have you come in contact with any confirmed Covid19 positive patients in the last 14 days? *

Yes

Are you experiencing shortness of breath or difficulty breathing? *

Yes

Are you experiencing other flu-like symptoms, such as gastrointestinal (stomach) upset, headache or fatigue? *

Yes

Have you experienced a recent loss of taste or smell? *

Yes

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes

Have you traveled in the past 14 days to any regions affected by Covid19? *

Yes

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