Covid Pre-Screen Name *FirstLastEmail *What is your current temperature *Have you or anyone you have been in close contact with had a temperature over 100.0 within the last 72 hrs? *Yes, I have.No, I have not.Do you have upper or lower respiratory tract issues, cough, sore throat, congestion, shortness of breath? *Yes, I have.No, I have not.Do you have digestive issues, nausea, vomiting, diarrhea? *Yes, I have.No, I have not.Do you have any loss of taste or smell? *Yes, I have.No, I have not.Have you or anyone you have been in close contact with been diagnosed with Covid-19 or Influenza? *Yes, I have.No, I have not.Have you traveled outside of the New England states (ME, NH, VT, MA, CT, RI) within the past 14 days? *Yes, I have.No, I have not.SignatureClear SignatureEmailSubmit
