COVID-19 Screening Form

COVID-19 screening form for healthcare providers.

Have you experienced any of the following symptoms in the past 14 days? *

FeverCoughShortness of breathLoss of taste or smellSore throatNone

Have you been in contact with anyone diagnosed with COVID-19 in the past 14 days? *

YesNo

Have you traveled internationally in the last 14 days? *

YesNo

Full Name *

Date of Birth *

Today's Date *

Signature *

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