Coronavirus COVID-19 Screening Questionnaire

In the last 10 days have you traveled outside your normal, daily routine?
Yes
No

Correct!

Wrong!

Have you been exposed to someone being tested for COVID-19?
Yes
No

Correct!

Wrong!

Have you been exposed to someone who has symptoms compatible with COVID-19?
Yes
No

Correct!

Wrong!

Do you or anyone in the household have any of the following symptoms? (not from an existing medical condition)

 

Fever

Yes
No

Correct!

Wrong!

Cough?

Yes
No

Correct!

Wrong!

Shortness of breath?

Yes
No

Correct!

Wrong!

Runny nose?

Yes
No

Correct!

Wrong!

Sore throat?

Yes
No

Correct!

Wrong!

Chills?

Yes
No

Correct!

Wrong!

Body aches?

Yes
No

Correct!

Wrong!

Fatigue?

Yes
No

Correct!

Wrong!

Headache?

Yes
No

Correct!

Wrong!

Loss of taste/smell?

Yes
No

Correct!

Wrong!

Eye drainage?

Yes
No

Correct!

Wrong!

Congestion?

Yes
No

Correct!

Wrong!

Are any members of your household in close contact with someone who is in quarantine due to exposure to COVID-19?
Yes
No

Correct!

Wrong!

Have you and your household followed the 6-foot social distancing rule while in public?
Yes
No

Correct!

Wrong!

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Coronavirus COVID-19 Screening Questionnaire

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