PHS Health & Wellness Survey
First Name *
Last Name *
Do you have any of these symptoms? fever, cough, hard to breathe, runny nose, sore throat, achy body, no taste or smell, watery eyes, stuffy nose, headache or very tired? *
Have you been close to someone who has been tested for COVID-19 or close to someone who has any of these symptoms? Fever, cough, hard to breathe, runny nose, sore throat, achy body, no taste or smell, watery eyes, stuffy nose, headache or very tired? *
Does anyone in your house have to stay away from others for 14 days because of being around someone else with COVID-19? *
Is there anything bothering you that you would like to talk to a counselor about?
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Where are you learning from? *
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