COVID-19 Questionnaire in Whiting, NJ

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?*

Yes
No

Have you had direct contact within the last fourteen (14) days with a person confirmed or suspected to be positive with COVID-19?*

Yes
No

In 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?*

Yes
No

Do 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?*

Yes
No

Have you been tested for COVID-19?*

Yes
No

Patient Temperature / °C) (Your temperature will be token upon arrival by o staff member with a digital no contact" thermometer)

Name

This field is for validation purposes and should be left unchanged.