Have you recently participated in any large gatherings of people you didn’t know?
 Yes  No

Have you or a member of your household traveled outside the United States within the last 14 days?
 Yes  No

Have you or an immediate family member been sick or had a fever in the last 14 days?
 Yes ​​​​​ No

Have you come into close contact with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?
 Yes  No

Do you have a fever greater than 99.6 degrees fahrenheit OR symptoms of possible COVID-19 Infection?
 Yes  No

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
 Vomiting  Diarrhea

Start date of symptoms: 

If you are experiencing symptoms, have you been tested for COVID-19?
 Yes  No

What was the COVID-19 Test Result?
 Positive  Negative

What was the date of the COVID-19 Test Result?

Patient or Parent/Guardian Signature

Date Signed