Covid Health Screening Name* First Last Phone*Email Do you have a fever greater than 100F?* Yes No In the past 14 days have you had close contact with an individual diagnosed with Covid-19?* Yes No Have you traveled to an "active or imminent outbreak" location or "at risk of an outbreak" location in the last 14 days?*See: https://covidactnow.org/?s=863169 Yes No Do you have a cough that started or has gotten worse in the last 48 hours?* Yes No Do you have shortness of breath that started in the last 48 hours?* Yes No Do you have muscle aches that started or has gotten worse in the last 48 hours?* Yes No In the last 48 hours have you felt significantly more tired than usual?* Yes No Do you have a runny nose or nasal congestion that started or has gotten worse in the last 48 hours?* Yes No Do you have a sore throat that started or has gotten worse in the last 48 hours?* Yes No Do you have nausea or diarrhea that started or has gotten worse in the last 48 hours?* Yes No In the last 48 hours, have you had new loss of taste or smell?* Yes No EmailThis field is for validation purposes and should be left unchanged.
