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Health Questionnaire
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* Indicates required question
What is your name?
Your answer
What is your phone number?
Your answer
1. Have you experienced any of the following COVID-19 symptoms within the last 14 days:
*
Shortness of breath or difficulty breathing
Fever (100 degrees or higher)
Muscle pain
Headache
Sore throat
New loss of taste or sense of smell
None of the above
Required
2. Are you waiting for COVID-19 test results?
*
Yes
No
3. Have you tested positive for COVID-19?
*
Yes
No
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