COVID-19 Questionnaire in Jackson Heights, NY

Name*

First Last

Date*

Do you have a fever?*

Do you have any shortness of breath?*

Do you have a dry cough?*

Do you have a runny nose?*

Do you have a sore throat?*

Do you have a new loss of smell or taste?*

Are you ill or caring for someone who is ill?*

Within the last 14 days, have you travelled to any foreign country or within the US?*

If yes, where?*

Have you been in contact with someone who has had a diagnosis of COVID-19?*

If yes, when?*