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Have you seen anyone since records were updated about this condition
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COVID 19 Screening
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Do you have a cough?
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Fever now or in the past 14-21 days
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Any contact with confirmed COVID case in the past 14 days
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Shortness of breath or difficulty breathing
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Flu like symptoms (GI upset, headache, fatigue)
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Loss of taste or smell
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Have you traveled to an area with high COVID numbers in the past 14 days
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High risk due to age (over 60) or medical history (heart disease, lung disease, kidney disease, diabetes, autoimmune)?
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COVID test: recent negative test
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Date tested mm/dd/yy
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COVID test: recent positive test
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Date tested mm/dd/yy
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Are you vacinated?
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How many shots have you had
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Vaccine brand (if multiple brands select more than one)
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