COVID Health Questionnaire
RequiredRequired Question(s)
Required 1.
Please enter the information indicated below.

First Name:
Last Name:

Required 2.
Have you or anyone you are in close contact with: 
 YES NO    
been diagnosed with COVID 19 in the last 14 days?    
traveled out of the country in the last 14 days?    
Required 3.
Are you currently experiencing any of the following symptoms?
 YES NO    
Fever Greater than 100.4°F (38°C)    
Severe Headache    
Muscle Pain / Weakness    
Respiratory Symptoms / Shortness of Breath    
New or Worsening Cough