Screening Questionnaire

Name*
First Last
Date*
MM slash DD slash YYYY
Phone*
Have you had any history of fever in the last 14 days?*
- Yes
- No
Have you had any respiratory illness such as cough or difficulty breathing in the last 14 days?*
- Yes
- No
In the last 14 days, have you or any member of your household had any contact with a known COVID-19 patient?*
- Yes
- No
Have you or anyone in your household been required to quarantine in the last 14 days?*
- Yes
- No