COVID-19 Patient Evaluation Form

First Name *

Last Name *

Phone Number *

Email

1. Have you tested positive for COVID-19 or are you awaiting results for a COVID-19 test?YesNo

2. Do you have any of the following:

• Cold or flu-like symptoms

• Fever

• Cough

• Sore throat

• Diarrhea or vomiting

• Shortness of breath or breathing difficulties

• Recent loss of taste or smell

YesNo

3. Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?YesNo

4. Within the last 14 days, have you or anyone in your household been in contact with a confirmed COVID-19 person?YesNo

5. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?YesNo