Full Name *

First Name

Last Name

Mobile Phone *

Country

(###)

###

####

Alternate Phone

Country

(###)

###

####

To your knowledge, have you traveled to any regions affected by COVID-19 within the last 2 weeks? *

Yes

No

To your knowledge, have you been directly in contact with anyone that has been tested positive for COVID-19 within the last 2 weeks? *

Yes

No

To your knowledge, have you been exposed to anyone who has been in contact with someone suspected of having COVID-19 within the last 2 weeks? *

Yes

No

To your knowledge, have you been exposed to anyone who has been in contact with someone that has tested positive for COVID-19 within the last 2 weeks? *

Yes

No

Have you had any of the following symptoms within the last 2 weeks? *

Fever or Chills

Shortness of Breath or Difficulty Breathing

Congestion or Runny Nose

Sore Throat

Coughing

Fatigued Muscles or Body Aches

Headaches

New Loss of Taste or Smell

Nausea or Vomiting

Diarrhea

None

Do you currently have COVID-19? *

Yes

No