Covid-19 Survey

Name *

First Name

Last Name

Phone *

(###)

###

####

Have you been in contact with anyone diagnosed with Covid-19 Symptoms? *

Yes

No

Have you been in contact with anyone exhibiting Covid-19 Symptoms? *

Yes

No

Do you have one of the following *

Fever

Shortness of breath

Uncontrolled cough

None of the above

Do you have two of the following? *

Abdominal pain

Diarrhea

Loss of taste or smell

Muscle aches

Severe headache

Sore throat

Vomiting

Non of the above