COVID-19 office screening

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* 1. Please enter your first and last names and Date of birth

First name

Last name

date of birth

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* 2. Have you or anyone in your household had any of the following symptoms in the past 21 days: sore throat, cough, chills, body aches for unknown reason, shortness of breath for unknown reason, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

Yes

No

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* 3. Have you or anyone in your household been tested for COVID-19?

Yes

No

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

Yes

No

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* 5. Have you or anyone n your household travelled anywhere in the US or abroad in the past 21 days?

Yes

No

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* 6. Have you or anyone in your household travelled on a cruise ship in the past 21 days?

Yes

No

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* 7. Are you or anyone in your household a health care provider or first responder?

Yes

No

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* 8. 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?

Yes

No

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* 9. Do you have any reason to believe that you or anyone in your household has been exposed to or acquired COVID-19?

Yes

No