COVID-19 Advocates Health Screening Question Title * 1. Name Question Title * 2. Have you had any of the following symptoms in the last 14 days, that is new or worsening or that you cannot attribute to another health condition? Headache Muscle Pain Fever or chills Cough Shortness of breath or difficulty breathing Unexplained Fatigue Muscle or body aches New loss of taste or smell Sore throat Congestion or runny nose (in absence of underlying reasons for symptoms such asseasonal allergies and post nasal drip) Nausea or vomiting Diarrhea Gastrointestinal Illness None Question Title * 3. Have you tested positive for COVID-19 in the past 14 days, or waiting for results? Yes No Question Title * 4. Have you had close contact with someone who tested positive for COVID-19 in the past 14 days? Yes No Question Title * 5. Have you had contact with someone suspected of having COVID-19 in the past 14 days? Yes No Question Title * 6. Have you, anyone you reside with/have visiting in your home or anyone you have had close contact with, traveled to/from a restricted state within the last 14 days? Please check the list of current restricted states here. Yes No Done
