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Health Questionnaire
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1
First & Last Name
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Date
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Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva in the past 14 days?
Yes
No
In the last 48 hours have you had any of the following NEW symptoms?
Check all that apply.
Fever of 100 F or above, or possible fever symptoms like alternating chills and sweating
Cough
Trouble breathing, shortness of breath or severe wheezing
Chills or repeated shaking with chills
Muscle Aches
Sore Throat
Loss of smell or taste, or a change in taste
Nausea, vomiting or diarrhea
Headache
None of the above
Has a public health official advised you to get tested for COVID-19?
Yes
No
Submit Form
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