Patient First & Last Name



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Are you immunocompromised?

Yes

No


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Have you been told (by a doctor, a health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating, or staying at home?

Yes

No


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Do you have any of the following symptoms?
• Fever and/or chills
• Cough or barking cough
• Shortness of breath
• Decrease or loss of taste or smell
• Muscle aches / joint pain
• Extreme tiredness
• Sore throat
• Runny or stuffy/congested nose
• Headache
• Nausea, vomiting, and/or diarrhea
• Abdominal pain
• Pink eye

Yes

No


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In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test, or other home-based self-testing kit?

Yes

No


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