1. Have you had a temperature above 100 degrees Fahrenheit in the past week?
2. Have you experienced shivering, shaking, or chills at any time over the past week?
3. Do you have a new, dry cough, headache, nausea or vomiting that started anytime in the past week?
4. Have you experienced new shortness of breath?
5. Do you live with or have you been in close contact with anyone who has tested positive for COVID-19 or is currently under recommended quarantine?
6. Have you recently lost your sense of taste or smell?
By signing this form I affirm and certify that all the answers to questions herein are
complete, true and correct to the best of my knowledge and belief