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* 1. Full Name:

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* 2. Date of Birth:

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* 3. Today's Date:

Date

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* 4. Did you get COVID-19? If so, when? Have you fully recovered and tested Negative?

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* 5. Did anyone in your home get COVID-19? If so, when? Have they fully recovered and tested negative?

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* 6. Are you experiencing any of the following symptoms? If so which ones?

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle pain
Headache
Sore throat
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea

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* 7. Have you been around anyone that is experiencing the follow symptoms?
If yes do they live with you and how long have they had symptoms?

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle pain
Headache
Sore throat
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea

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* 8. Do you have a history of upper respiratory problems such as Asthma?

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* 9. In the last month have you traveled outside of New York or been in contact with someone who has?

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* 10. Have you been on a cruise or an airplane in the last month?

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