COVID-19 Screening Form

Your Name

Do you have fever or have you felt hot or feverish recently (14-21 days)?

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Are you having shortness of breath or other difficulties breathing?

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Do you have a cough?

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Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

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Have you experienced recent loss of taste or smell?

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Are you in contact with any confirmed COVID-19 positive patients?

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Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

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Have you traveled in the past 14 days to any regions affected by COVID-19?

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Thank you! Your answer is recorded.

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