Questions to Ask Yourself About the Coronavirus (COVID-19) Name* First Last Phone*Email Are You at Risk for COVID-19Please complete the questions below.1. Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?* Yes No 2. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?* Yes No Signature*Date* MM slash DD slash YYYY Δ
