Health Questionnaire

  1. Have you traveled outside the country in the last 14 days?
  2. During the last 14 days, have you had contact (close or far) with anyone who has lab-confirmed COVID-19, is under investigation for COVID-19, or is hospitalized or being treated at home for a respiratory or febrile illness?
  3. During the last 14 days, have you had close or distant contact (close=within 6 feet for 5-10 minutes,  distant=more than 6 feet for 90+ minutes) with anyone who has any symptoms of illness?
  4. Have you had any of the following symptoms in the past 14 days?
  • Fever or chills
  • Unexplained cough, shortness of breath, or sore throat
  • Pneumonia/flu symptoms
  • Loss of smell or change in the sense of taste
  • Diarrhea
  • Tiredness, aches
  1. Do you work in the medical field or other ‘high-risk’ setting?