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COVID-19 Questionnaire
Please fill out this questionnaire and answer all questions.
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Do you have any of the following symptoms?
Fever
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestions or runny nose
Nausea or vomiting
Diarrhea
Other:
Have you been in contact with anyone displaying symptoms, exposed, or diagnosed with COVID-19?
Yes
No
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Have you tested positive for COVID-19 within the past 14 days?
Yes
No
Other:
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I certify, the information above is accurately answered to the best of my knowledge. Type name below.
Your answer
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