This screening tool should not be used in lieu of consulting a medical professional. This form is not meant to formally diagnose your condition, but rather provide you with more information about the virus. Always contact a medical professional for treatment of symptoms or emergencies.

If there is an active life-threatening emergency, please call 911.

Your Name: *

Your Temperature: *

Are you experiencing a fever AND any of the following symptoms?

Cough
Runny Nose
Sore Throat

YesNo

Are you experiencing shortness of breath? *YesNo

COVID-19 Screening-Internal

COVID-19 Screening Tool INTERNAL USE ONLY