PreScreening Questions Name* First Last Date* Date Format: MM slash DD slash YYYY Do you have fever or have you felt hot or feverish recently (14-21 days)?*YesNoAre you having shortness of breath or other difficulties breathing?*YesNoDo you have a cough?*YesNoAny other flu-like symptoms, such as gastrointestional upset, headache or fatigue?*YesNoHave you experienced recent loss of taste or smell?*YesNoAre you in contact with any confirmed COVID-19 positive patients?*YesNoIs your age over 60?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YesNoHave you traveled outside the state or to any infected areas in the past 14 days?*YesNoCommentsThis field is for validation purposes and should be left unchanged.