Covid Questionnaire Enter Your contact information My name * My e-mail * Questions Do you have anyone in your home / have you interacted with anyone that is at a higher risk for contraction? (nurses, essential workers, etc.) * No Yes Do you have anyone in your home that could be more susceptible to contracting COVID-19? * No Yes Have you had contact with a person known to be infected, potentially infected, or exposed to someone infected with COVID-19 within the previous 14 days? * No Yes Have you or someone you’ve been in contact with traveled domestically or internationally in the last 14 days? * No Yes Have you or someone you’ve been in contact with attended a gathering where proper social distancing protocol was not followed in the past 14 days? * No Yes Have you had a fever, cough, shortness of breath, difficulty breathing, chills, muscle pain, sore throat, or new loss of taste or smell that cannot be attributed to another health condition in the past 2-14 days? * No Yes Submit