COVID-19 Wellness Form Name* First Last Date* MM slash DD slash YYYY Do you have a cough?* Yes No Have you had a fever in the last 14-21 days?* Yes No Have you come in contact with a confirmed Covid-19 positive patient in the last 14 days?* Yes No Are you experiencing any shortness of breath or difficulty breathing?* Yes No Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?* Yes No Have you experienced recent loss of taste or smell?* Yes No Do you have heart disease, lung disease, kidney disease, diabetes, or auto-immune disorders?* Yes No PhoneThis field is for validation purposes and should be left unchanged.
