Name* First Last Email* Phone*Do you have a cough?* Yes No Do you have a fever now or have you in the past 14-21 days?* Yes No Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?* Yes No Are you experiencing 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 Are you over the age of 60?* Yes No Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?* Yes No Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)* Yes No
