COVID-19 Questionnaire

Vaccination Status:

Fully Vaccinated

Partially Vaccinated

Not Vaccinated

Have you had any fever, cough, or shortness of breath within the last 140 days? *

No

Yes

Have you had a test for Coronavirus in the last two weeks? *

No

Yes: The results were negative

Yes: The results were positive

Have you had any recent changes in your health? *

No

Yes (describe below)

Describe any changes in your health

First Name *

Last Name *

Date *