Have you recently participated in any large gatherings of people you didn’t know?
Have you or a member of your household traveled outside the United States within the last 14 days?
Have you or an immediate family member been sick or had a fever in the last 14 days?
Have you come into close contact with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?
Do you have a fever greater than 99.6 degrees fahrenheit OR symptoms of possible COVID-19 Infection?
If you answered YES to the last question, please select any and all symptoms you are experiencing:
Fever Chills Cough Pneumonia Sore Throat Shortness of Breath
Muscle Aches Loss of Smell Loss of Taste Headache Abdominal Pain
Start date of symptoms:
If you are experiencing symptoms, have you been tested for COVID-19?
What was the COVID-19 Test Result?
What was the date of the COVID-19 Test Result?
Patient or Parent/Guardian Signature