Name *

Have you had any new cough? *

Have you had any shortness of breath? *

Have you had a fever? *

Have you had a sore throat? *

Have you had a headache? *

Have you had chills? *

Have you lost the sense of smell or taste? *

Have you had any diarrhea or vomiting within the last 24 hours? *

Have you been in close contact with any person experiencing covid-19 symptoms? *