Covid Pre-screening

Are you, or have you experienced any symptoms of the Novel Coronavirus/COVID-19, including, but not limited to cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or loss of taste or smell within the last 21 days? *

Yes
No

Have you or anyone in your household been tested for COVID-19 in the last 21 days? *

Yes
No

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *

Yes
No

Have you or anyone in your household traveled internationally in the past 21 days? *

Yes
No

Have you or anyone in your household traveled to another US state in the past 21 days? *

Yes
No

Have you or anyone in your household traveled on a cruise ship in the last 21 days? *

Yes
No

Are you or anyone in your household a health care provider or emergency responder? *

Yes
No

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19 in the past 21 days? *

Yes
No

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19 in the past 21 days? *

Yes
No

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19 within the past 21 days? *

Yes
No

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