Patient Name *

First Name

Last Name

1) Had a fever over 100.4 F? *

Yes

No

2) Had a dry cough? *

Yes

No

3) Had shortness of breath? *

Yes

No

4) Had loss of taste or smell? *

Yes

No

Have you been around anyone who has tested positive for COVID-19 in the past 14 days? *

Yes

No

Have you travelled internationally in the last 14 days? *

Yes

No