COVID-19 Screening - HFT dashboard

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COVID-19 Screening for Clinicians

* Indicates required field

Name *

First

Last

Do you have a new cough that you cannot attribute to another health condition?

COUGH *

YES NO

Do you have new shortness of breath that you cannot attribute to another health condition?

SHORTNESS OF BREATH *

YES NO

Do you have a new fever (100.4°F or higher) or chills that you cannot attribute to another health condition?

FEVER *

YES NO

Do you have any of the following symptoms?

CHECK ALL THAT APPLY *

fatigue congestion or runny nose sore throat new loss of taste or smell headache diarrhea muscle or body aches nausea or vomitting NONE OF THESE

Have you come into close contact (within 6 feet for more than 15 minutes) with someone who has a laboratory-confirmed COVID-19 diagnosis in the past 14 days?

CLOSE CONTACT *

YES NO

BY CLICKING "SUBMIT" I AM CERTIFYING THAT THE RESPONSES PROVIDED ABOVE ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

Submit

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