COVID-19 Questionnaire Salutation*Mr.Mrs.Ms.Dr.Name* First Last Date* Date Format: MM slash DD slash YYYY 1. Have you had any of the symptoms of COVID-19, including fever, headaches, cough, shortness of breath, or loss of smell and taste?*YesNoIf yes, how long did symptoms last?*How long have symptoms been absent?*2. Have you been around any individual who has had these symptoms or tested positive for the SARS-CoV-2 virus that causes COVID-19?*YesNoIf yes, how long has it been since you have been in contact with them?*3. Do you live in an assisted living facility or a Nursing Home?*YesNo4. Have you tested positive for the SARS-CoV-2 virus that causes COVID-19?*YesNoIf yes, were you hospitalized?*YesNoRelease date* Date Format: MM slash DD slash YYYY Last test date* Date Format: MM slash DD slash YYYY PositiveNegative
