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.
Have you traveled in the last two weeks to or from any of the following countries?
YesNo
Have you been in close contact or live with someone who has traveled to the above countries and is now sick with a respiratory illness?
Have you been in close contact or live with someone known to have coronavirus (COVID-19)?
Have you been told by a healthcare provider that you may have been exposed to coronavirus (COVID-19)?
Are you experiencing a fever AND any of the following symptoms?
Do any of these apply to you?
You have LOW to NO RISK of COVID-19 exposure. Widespread testing in NOT currently available. TAKE THESE STEPS: Practice self-isolation and social distancing. Wash your hands regularly for 20 seconds with soap and water. Regularly disinfect common touch areas. If you have an emergency or life-threatening problem, CALL 911. Call your primary healthcare provider if non-emergent medical evaluation is needed. If something changes, please use this tool again.
Widespread testing in NOT currently available.
TAKE THESE STEPS:
You are at MEDIUM RISK of COVID-19 exposure. Widespread testing in NOT currently available. TAKE THESE STEPS: Take steps to isolate yourself from group settings, including family. If you have an emergency or life-threatening problem, CALL 911. Call your primary healthcare provider if non-emergent medical evaluation is needed. Call ahead to let them know you are coming. Do NOT go to your local emergency department for COVID-19 testing. The emergency department is only for those who need the most critical care. Controlled travel: Local travel only by private vehicle while symptomatic person is wearing a face mask. Wash your hands regularly for 20 seconds with soap and water. Regularly disinfect common touch areas. IF YOU HAVE NO SYMPTOMS: Remain at home Practice social distancing. Postpone all travel and group functions.
IF YOU HAVE NO SYMPTOMS:
You are at HIGH RISK of COVID-19 exposure. Widespread testing in NOT currently available. TAKE THESE STEPS: Immediately isolate yourself from group settings, including family. Like secluding yourself to a room by yourself, and use caution in common areas. If you have an emergency or life-threatening problem, CALL 911. Call your primary healthcare provider if non-emergent medical evaluation is needed. Call ahead to let them know you are coming. Do NOT go to your local emergency department for COVID-19 testing. The emergency department is only for those who need the most critical care. Controlled travel: Local travel only by private vehicle while the symptomatic person is wearing a face mask and SHOULD BE AVOIDED. Wash your hands regularly for 20 seconds with soap and water. Regularly disinfect common touch areas. IF YOU HAVE NO SYMPTOMS: Quarantine in your home; NO TRAVEL Do NOT attend public, group, or family activities AT ALL. Monitor your temperature twice a day and notify your primary healthcare provider if fever or other symptoms develop or worsen.