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KMR Health Screening
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* Indicates required question
Email
*
Your email
NAME:
Your answer
DATE:
Your answer
In the past 14 days, have you:
Had close contact with an individual diagnosed with COVID-19?
Yes
No
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If you answered "yes", self-quarantine and call your primary care physician's office or urgent care facility for further directions.
In the past 24 hours, have you experienced:
New or worsening cough:
Yes
No
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Shortness of breath or difficulty breathing:
Yes
No
Clear selection
Or Two (2) or more of the following:
Fever.
Fever is a temperature of 100.4 F or higher
Yes
No
Clear selection
Chills:
Yes
No
Clear selection
Muscle pain:
Yes
No
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Headaches:
Yes
No
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Sore Throat:
Yes
No
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Loss of taste or smell:
Yes
No
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If you answered "yes" to the first two symptoms above, or "yes" to two (2) or more of the last five symptoms please self-isolate at home and contact your primary care facility.
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