COVID-19 Wellness Check Question Title * 1. Name (Required.) Question Title * 2. Phone (Required.) Question Title * 3. Email (Required.) Question Title * 4. Which program are you attending? (Required.) Question Title * 5. Do you have a cough? (Required.) Yes No Question Title * 6. Do you have a fever, or have you had one in the past 14-21 days? (Required.) Yes No Question Title * 7. Are you experiencing shortness of breath or having difficulty breathing? (Required.) Yes No Question Title * 8. Have you experienced recent lost sense of taste or smell? (Required.) Yes No Question Title * 9. Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? (Required.) Yes No Question Title * 10. Have you come in contact with any confirmed or suspected COVID-19-positive people in the last 14 days? (Required.) Yes No SUBMIT