Name

First Name

Last Name

2. Do you have any of the following signs or symptoms?

Please check all that apply

New onset of cough

Sore throat

Worsening chronic cough

Shortness of breath

Difficulty Breathing

New loss or decrease in sense of smell or taste

Runny nose (not allergy related)

Sneezing (not allergy related)

Unexplained fatigue or malaise

Hoarse voice

Difficulty swallowing

Headache

Nasal Congestion

Nausea/vomiting, diarrhea, abdominal pain

Chills