COVID19

COVID19

COVID-19 trace form

Do you have new onset cough? *
Do you have new onset fever? *
Are you short of breath? *
Have you noticed a loss of your sense of smell or taste? *
What is your gender? *
Do you have a chronic medical condition? (i.e. Diabetes, Heart Disease, Immune Compromised) *
Are you pregnant? *
To the best of your knowledge, in the last month, have you had close contact with a person known to have COVID-19? *
Have you been tested for COVID-19? *