COVID-19 Form

Submission On : 17-01-2022 16:45:47

1) Have you or anyone in your household had any of the following symptoms in the last 24 hours?


Yes No
Cough

Shortness of breath or difficulty breathing


OR at least TWO of the following symptoms in the last 24 hours:

Yes No
Fever (usually 38°C or higher)

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell


2) In the last 14 days have you:

Yes No
Been in contact with someone who was diagnosed with COVID-19?

Been in close contact with someone who had COVID-19 symptoms?

Traveled internationally or taken a cruise








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