COVID-19 Questionnaire Salutation*Mr.Mrs.Ms.Dr.Name* First Last Date* 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?* Yes No If 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?* Yes No If 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?* Yes No 4. Have you tested positive for the SARS-CoV-2 virus that causes COVID-19?* Yes No If yes, were you hospitalized?* Yes No Release date* MM slash DD slash YYYY Last test date* MM slash DD slash YYYY Positive Negative
