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* 1. Personal Information

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* 2. Have you traveled out of state in the last 21 days?

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* 3. Have you tested positive for COVID-19 in the past 28 days?

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* 4. Have you been antibody tested with a blood drawn technique?

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* 5. Have you been antibody tested with a finger prick technique?

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* 6. Do you have a fever or have you felt hot or feverish in the last 7-21 days?

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* 7. Have you experienced shortness of breath or difficulties breathing in the last 7-14 days?

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* 8. Do you presently have a cough?

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* 9. Do you possess any flu-like symptoms other than fever: headache, fatigue, chills, GI upset?

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* 10. Have you experienced a recent loss of taste or smell?

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* 11. Are you in contact with any COVID-19 positive patients in the last 7-21 days?

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* 12. Have you felt the need to self-quarantine in last 14 days?

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* 13. Are you 60 years of age or older?

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* 14. Do you have heart disease, lung disease, kidney disease, diabetes, or an auto-immune disorder?

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