COVID-19 QUESTIONNARE
First and Last Name: *
Have you or a family member been exposed to COVID-19? *
Does the patient and/or others accompanying you have a cough? *
Does the patient and/or others accompanying you have shortness of breath? *
Does the patient and/or others accompanying you have a fever? *
Does the patient and/or others accompanying you have tightness in chest? *
Does the patient and/or others accompanying you have a headache? *
Does the patient and/or others accompanying you have a sore throat? *
Does the patient and/or others accompanying you have a new loss of taste or smell? *
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