First Name

Last Name

Email Address

Phone

Have you been fully vaccinated for covid (first dose & second dose completed)? Have you been fully vaccinated for covid (first dose & second dose completed)? Yes No

Do you have fever or have you felt hot or feverish recently? (14-21 days) Do you have fever or have you felt hot or feverish recently? (14-21 days) Yes No

Are you having shortness of breath or other difficulties breathing? Are you having shortness of breath or other difficulties breathing? Yes No

Do you have a cough? Do you have a cough? Yes No

Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue? Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue? Yes No

Have you experienced recent loss of taste or smell? Have you experienced recent loss of taste or smell? Yes No

Are you in contact with confirmed COVID-19 positive patients? Are you in contact with confirmed COVID-19 positive patients? Yes No

Is your age over 60? Is your age over 60? Yes No

Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? 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)? Have you traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)? Yes No

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