Covid-19 QuestionnaireNameDate Of BirthMonthDayYearWithin the last 14 days, have you experienced any of the following symptoms? *FeverChillsBody Ache / WeaknessMuscle Pain and Joint PainSore ThroatCough (new or worsening)Runny NoseShortness of BreathChest PainHeadacheLoss of tasteLoss of smellIF YOU DO NOT HAVE ANY OF THE FOLLOWING SYMPTOMS CHECK THIS BOXCheck all that may apply:Have you had a positive COVID-19 test in the last 1 month? *YESNOIf so, when was the test done? Please give exact date.Within the last 14 days, have you had close contact with someone who is currently sick or confirmed with COVID-19? *YESNOHave you received your COVID-19 Vaccine? *YESNOIf so, when and how many?DateSubmit FormPlease do not fill in this field.
