Surveypoint

Q1

First Name

Full Name*

Q2

Last Name

Full Name*

Q3

Phone Number

Phone Number*

Q4

Email*

Q5

Check the conditions that apply to you or to any members of your household and/or persons you come in contact with:*

Asthma

Cancer

Cardiac disease

Diabetes

Hypertension

Immunocompromized

None of the above

Q6

Are you currently taking any immunosuppressive medication (ex: prednisone(steroids), meds for lupus, meds for psoriasis, meds for hidradenitis, arthritis, etc)*

Yes

No

Q7

Are you experiencing any of the following symptoms:*

Cough

Fever (99.9° or higher)

Chest congestion

Labored breathing

Wheezing

Sore throat

Chills/shaking

Muscle/joint aches

Loss of taste

Loss of smell

None of the above

Q8

Have you experienced any of the following symptoms In the past 14 days:*

Cough

Fever (99.9° or higher)

Chest congestion

Labored breathing

Wheezing

Sore throat

Chills/shaking

Muscle/joint aches

Loss of taste

Loss of smell

None of the above

Q9

Has anyone in your household experienced any of the following symptoms In the past 14 days:*

Cough

Fever (99.9° or higher)

Chest congestion

Labored breathing

Wheezing

Sore throat

Chills/shaking

Muscle/joint aches

Loss of taste

Loss of smell

None of the above

Covid 19 Screening -Form Fill

First Name

Last Name

Phone Number

Email*

Check the conditions that apply to you or to any members of your household and/or persons you come in contact with:*

Are you currently taking any immunosuppressive medication (ex: prednisone(steroids), meds for lupus, meds for psoriasis, meds for hidradenitis, arthritis, etc)*

Are you experiencing any of the following symptoms:*

Have you experienced any of the following symptoms In the past 14 days:*

Has anyone in your household experienced any of the following symptoms In the past 14 days:*