COVID-19 Screening Questionnaire Your Name (required) Your Email (required) Have you tested positive for COVID-19 or are you awaiting results for a COVID-19 test? YesNo In the past 14 days, have you been in contact with anyone that has tested positive for COVID-19? YesNo Are you experiencing shortness of breath or any other breathing difficulties? YesNo Do you, or have you recently had a fever, cough, or sore throat? YesNo Have you experienced recent loss of taste, smell, or any other symptoms not normal to you? YesNo Even if you do not currently have any of the above symptoms, have you experienced any of them in the last 14 days? YesNo Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YesNo Are you in direct contact with any elderly or systemically fragile individuals? YesNo Do you currently have a fever? YesNo
