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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