covid-19 scan form

Name*

Email*

Do you have fever over 100F or signs of fever such as chills, sweats, feverish?*

Do you have any of the following: sweat/fever/chills?*

Do you have any of the following: cough, sore throat, shortness of breath or chest tightening?*

Do you have any of the following: runny nose, nasal congestion?*

Do you have any of the following: nausea, vomiting, diarrhea?*

Do you have any of the following: body aches (Myalgia), loss of smell and/or taste?*

Have you traveled outside of the state or internationally in the last 14 days?*

Have you been in close contact in the last 14 days with someone with a diagnosis of COVID-19?*

Please enter date and time of the form submission*

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