Name *

First Name

Last Name

Do you have a fever?

Yes

No

Do you have any shortness of breath?

Yes

No

Do you have a dry cough?

Yes

No

Do you have a runny nose?

Yes

No

Do you have a sore throat?

Yes

No

Within the last 14 days, have you traveled to any foreign country?

Yes

No

Within the last 14 days, have you traveled within the United States?

Yes

No