COVID-19 Questionnaire

COVID-19 SCREENING QUESTIONNAIRE
(AS OF 3/31/2020)
An outbreak of 2019 Coronavirus (COVID-19) requires early and effective detection of suspected cases to limit the risk of exposure to others. We are kindly requesting you to complete the following questions.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Within the last 24 hours, have you had any of the following symptoms? Choose all that apply. To select more than one choice, press CTRL key as you click.
During the last 14 days have you been to ANY foreign country or on a cruise?
- Yes
- No
If YES, please specify the city/location and when:
Did you spend time (more than 5 minutes) within 6 feet distance with a person who had been to ANY foreign country?
- Yes
- No
Did you spend more than 5 minutes within 6 feet of a person who did have, or was under investigation for COVID-19?
- Yes
- No
If you have any of the symptoms listed above, you are required to contact your medical provider and NOT enter the STI Group Facility.
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