COVID-19 Wellness Form Name* First Last Date* Date Format: MM slash DD slash YYYY Do you have a cough?*YesNoHave you had a fever in the last 14-21 days?*YesNoHave you come in contact with a confirmed Covid-19 positive patient in the last 14 days?*YesNoAre you experiencing any shortness of breath or difficulty breathing?*YesNoAre you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*YesNoHave you experienced recent loss of taste or smell?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes, or auto-immune disorders?*YesNoPhoneThis field is for validation purposes and should be left unchanged.