COVID-19 Questionnaire Name*Phone*Email* Have you within the last fourteen (14) days traveled to a country where community-based spread of COVID-19 is occurring or to any other geographic region in the United States with sustained community transmission of COVID-19?*YesNoHave you had direct contact within the last fourteen (14) days with a person confirmed or suspected to be positive with COVID-19?*YesNoIn the lost fourteen (14) days, have been in close contact with anyone who has experienced any of the following cold or flu-like symptoms - fever, cough, shortness of breath, difficulty breathing sore throat, body aches, or lack of taste or smell?*YesNoDo you currently have, or have you experienced any of the following cold or flu-like symptoms within the last fourteen (14) days fever, cough, shortness of breath, difficulty breathing, sore throat, body aches, or lack of taste or smell?*YesNoHave you been tested for COVID-19?*YesNoPatient Temperature / °C) (Your temperature will be token upon arrival by o staff member with a digital no contact" thermometer)NameThis field is for validation purposes and should be left unchanged. 16223