First Name:
Last Name:
Email:
Telephone Number:

Have you had any of the symptoms listed below that were not attributable to another condition within the last month? Check all that apply.

Fever
Shortness of breath
Headache
Chills
Muscle fatigue or pain
Cough

Were you in contact with someone who previously tested positive for COVID-19 within the last month?

Yes
No
If yes, please elaborate on your situation below. For example: when did they test positive, what countermeasures have you taken, and how much contact did you have with them?