COVID Screening Questionaire

Today, or in the past 24 hours, have you or any household members had any of the following symptoms?

Fever (99.7° F or greater) or taken a fever suppression medication, Cough, Shortness of breath or difficulty breathing, Sore throat, New loss of taste or smell, Chills, Head or muscle aches, Nausea, Diarrhea, Vomiting?
In the past 14 days, have you been near (within 6-feet) anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?
In the past 14 days, have you been near (within 6-feet) anyone who has tested positive for COVID-19?
Have you tested positive for COVID-19 or been tested for COVID-19 and are waiting to receive test results, or are you presumptively positive for COVID-19?
In the past 14 days, have you been on a commercial flight or traveled outside of the United States?

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