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CORONAVIRUS DISEASE (COVID-19) SCREENING QUESTIONNAIRE

Have you traveled outside our local area in the last 14 days?

Have you been in close contact with another person who has been diagnosed with COVID-19 or another person under investigation for COVID-19?

Do you have a cough, fever or shortness of breath?

Contact your primary physician or public health department as soon as possible to determine if you should be seen or tested.

Visit https://www.naccho.org/membership/lhd-directory for information on how to contact your local health department and https://www.cste.org/page/EpiOnCall for information on how to contact your state health department.

First Name

Last Name

Date Of Birth

Signature of Patient or Legal Guardian

Date