COVID-19 Pre-Screening Questionnaire
COVID-19 Pre-Screening Questionnaire
First Name
*
Last Name
*
Email
*
1. Have you experienced any of the following symptoms within the last 14 days? Check all that apply.
*
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease of loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue / malaise / muscle aches (myalgias)
Nausea / vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose or nasal congestion without other known cause
None of the above
2. Have you been diagnosed of suspected of having COVID-19?
*
Yes
No
If yes, when? (eg. July 10)
3. Are any of your family members or immediate/close contacts currently sick or experiencing fever, cough, shortness of breath, or flu-like symptoms?
*
Yes
No
4. Have any of your family members or immediate/close contacts been diagnosed with covid-19?
*
Yes
No
If yes, when? (eg. July 10)
5. Have you travelled to the U.S. Or internationally within the past 14 days?
*
Yes
No
If yes, where and when?
6. Have any of your family members travelled to the U.S or internationally within the past 14 days?
*
Yes
No
If yes, where and when?
If you are human, leave this field blank.
Submit