COVID-19 Screening

Name

Please fill in your full name

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Email

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Current Temperature

input current body temperature

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Have you had a fever in the last 24 hours of 100°F or above?

Do you now, or have you recently had, any respiratory or flu symptoms, cough, sore throat, or shortness of breath?

Have you lost your sense of taste or smell?

Do you now, or have you recently had, any chills, muscle aches or new rashes or lesions?

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Have you traveled to a high-transmission area within the last 14 days?

How is your social distancing going?

Please explain your social distancing rules

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