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Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body ach
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New Yes / No
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Have you or anyone in your household been tested for COVID-19?
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New Yes / No
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Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health
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New Yes / No
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Have you or anyone in your household traveled in the U.S. in the past 21 days?
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New Yes / No
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Have you or anyone in your household traveled on a cruise ship in the last 21 days?
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New Yes / No
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Are you or anyone in your household a health care provider or emergency responder?
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New Yes / No
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Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested pos
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New Yes / No
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Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
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New Yes / No
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To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?
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New Yes / No
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