COVID-19 Screening
Instructions
Please answer the following questions as it pertains to you and anyone accompanying you today.
DO YOU LIVE IN THE SAME HOUSEHOLD or have you had contact with anyone who is known to have a positive COVID-19 test result in the last 14 days?
Yes
No
Have you been in close contact with anyone who is confirmed positive COVID-19 or is a suspected case of COVID-19 without PPE (mask/face shield)
Within the past 10 days
Less than 6 feet distance
Greater then 15 minutes
Yes
No
Are you experiencing Shortness of Breath?
Yes
No
Are you experiencing a Cough?
Select all that apply. Select 'None' if you do not have any symptoms.
None
New or Worsening
History of Cough
Related to a non COVID medical condition
Are you experiencing at least two of the following symptoms?
Select all that apply. Select 'None' if you do not have any symptoms.
None
Sore Throat
Chills
Repeated Shaking with chills
Headache
Muscle Pain
New Loss of Taste or Smell
Fever
Diarrhea
Have you been tested for COVID-19 DUE TO A POSSIBLE EXPOSURE and are awaiting test results?
Yes
No
Have you tested positive for COVID-19 and have not been cleared to leave quarantine (at least ten days since positive test, no fever for 24 hrs without using fever reducing meds, symptoms resolving)?
Yes
No
Submit