COVID-19 Questionnaire

COVID-19 Questionnaire

COVID-19 Health Questionnaire

Vaccination Status:
Have you had any cough, shortness of breath, other respiratory problems, or other symptoms associated with COVID-19 since January 2020? *
Have you had fever within the last 30 days? *
Have you been in contact with anyone suspected or with confirmed positive test to coronavirus? *
Have you been tested for Coronavirus? *
Have you traveled internationally within the last 30 days? *
Have you traveled to any states with recent increase in number of COVID-19 cases within the last two weeks? *
Have you been in any large gatherings including protests, religious events / programs, or social events within the last two weeks? *
How would you describe your personal discipline in social distancing and mask wearing habits?
Have you had any recent changes in your health? *