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, and 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 Covid?*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 had the COVID virus?*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
