Name* First Last Email* Phone*Do you have a cough?*YesNoDo you have a fever now or have you in the past 14-21 days?*YesNoHave you come in contact with any confirmed COVID-19 positive patients in the last 14 days?*YesNoAre you experiencing 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?*YesNoAre you over the age of 60?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YesNoHave you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*YesNo
