Patient First & Last Name



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Are you fully vaccinated against COVID-19 and/or aged 11 or younger?

Yes

No


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In the last 14 days, have you been directed by a border agent to comply with federal quarantine requirements due to international travel?

Yes

No


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In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you experienced any of the following symptoms?
• Fever and/or chills
• Cough or barking cough
• Shortness of breath
• Decrease of loss of taste or smell
• Muscle aches / joint pain
• Extreme tiredness
• Sore throat
• Running or stuffy/congested nose
• Headache
• Nausea, vomiting, and/or diarrhea

Yes

No


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Do any of the following apply:
- You live with someone who is currently isolating because of a positive COVID-19 test
- You live with someone who is currently isolating because of COVID-19 symptoms
- You live with someone who is isolating while waiting for COVID-19 test results

Yes

No


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In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?

Yes

No


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Has a doctor, health care provider, or public health unit told you that you should be currently isolating (staying at home)?


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