Covid-19 Assessment This form is an assessment to see if testing if required. 1. Have you had in-person close contact with a person diagnosed with coronavirus disease (COVID-19)?* Yes No Unknown 2. Have you traveled internationally to any of the following in the last 14 days?* Africa Antarctica Asia Australia Europe South America No Travel 3. How do you feel today?* I am feeling sick I am feeling fine Hidden4. What is your temperature?* Temperature above 100.4 °F (38 °C) Older than 65 and temperature above 99.6 °F (37.5 °C) I feel feverish I don't know Normal 5. Do you have any of the following?* Cough - dry (nonproductive) Cough - wet (productive) Shortness of breath Wheezing None of the above 6. Do you have any of the following?* Headache Runny Nose Itchy Eyes Watery Eyes Sneezing None of the above 7. Does any of the following apply to you:* High blood pressure / Hypertension Heart Disease Lung Disease Diabetes Immunosuppressed by medication or HIV Resident of Nursing Home or Chronic Care Facility Pregnant or post-partum within 2 weeks of delivery None of the above 8. What is your age?* Younger than 20 20 - 39 40 - 59 60 - 69 70 - 79 80 or older 9. Are you a first responder or healthcare worker?* Yes No Δ