Covid-19 Self Assessment Tool

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First Name:

Last Name:

Email Address:

Cell Number:

Street Address 1:

Street Address 2:

City:

State:

ZipCode:

This form is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Please check all that apply.

New Shortness of Breath:

Yes No Not Sure

New Cough:

Yes No Not Sure

Chills/Body Aches:

Yes No Not Sure

Nausea/Vomiting/Diarrhea:

Yes No Not Sure

Loss of Sense of Taste or Smell:

Yes No Not Sure

Headache:

Yes No Not Sure

Sore Throat:

Yes No Not Sure

Temperature above 100.0° F:

Yes No Not Sure

Have you been in contact with someone with known or suspected coronavirus (COVID-19) within the past 14 days:

Yes No Not Sure

To book an appointment:

If you have a general question about COVID-19, please call our COVID-19 information line Monday-Friday from 8:00 am - 6:00 pm at 201-227-6096