COVID-19 Questionnaire CompanyThis field is for validation purposes and should be left unchanged.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) Δ
