Name *

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

1. Have you, or anyone in your household, had a fever in the last 14 days of 100 degrees Fahrenheit or above? *

Yes

No

2. Have you, or anyone in your household, within the last 14 days, had any respiratory or flu symptoms, cough, sore throat, shortness of breath or difficulty breathing? *

Yes

No

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19, has been exposed to Covid-19, or has coronavirus-type symptoms? *

Yes

No

4. Have you, or anyone in your household, within the last 14 days, had any chills, fatigue, new head or body aches, new loss of taste or smell, or new rashes or lesions? *

Yes

No

5. Have you tested positive for Covid-19 (and consider yourself recovered) or do you strongly suspect you may have had Covid-19 (and consider yourself recovered)? *

Yes

No

6. Are you fully vaccinated for Covid-19? *

Yes

No