COVID-19 Screening Form
Do you have fever or have you felt hot or feverish recently (14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you in contact with any confirmed COVID-19 positive patients?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you traveled in the past 14 days to any regions affected by COVID-19?
Thank you! Your answer is recorded.