Pre-Assessment Form

Name*

First Last

DOB*

MM

DD

YYYY

Phone*

Email*

Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days?*

Yes
No

Check all that apply:*

Fever of 100.5 F or above, or possible fever symptoms like alternating chills and sweating
Cough
Trouble breathing, shortness of breath, or severe wheezing
Chills or repeated shaking with chills
Muscle aches
Sore throat
Diarrhea
Loss of smell or taste, or change in taste
None of the Above

Patient Pre-Assessment Form

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