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COVID-19 Patient Screening Form

Name*

First Name

Last Name

Date/Time*

Do you have a fever or do you think your temperature is above 100.4°F?*

No Yes

Are you experiencing shortness of breath or having trouble breathing?*

No Yes

Do you have a dry cough?*

No Yes

Do you have a runny nose?*

No Yes

Have you recently lost or had a reduction in your sense of smell or taste?*

No Yes

Do you have a sore throat?*

No Yes

Are you experiencing chills or repeated shaking?*

No Yes