COVID-19 Screening Tool

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?

  • China
  • Iran
  • Italy
  • Japan
  • South Korea

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?

YesNo

Have you been in close contact or live with someone known to have coronavirus (COVID-19)?

YesNo

Are you following recommended precautions and in-home isolation?

YesNo

Have you been told by a healthcare provider that you may have been exposed to coronavirus (COVID-19)?

YesNo

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

  • Cough
  • Runny Nose
  • Sore Throat

YesNo

Are you experiencing shortness of breath?

YesNo

Do any of these apply to you?

  • 65 years old or older
  • Cardiac disease (e.g. coronary artery disease, congestive heart failure)
  • Pulmonary disease (e.g. asthma, chronic obstructive pulmonary disease)
  • Immunosuppression (e.g. chemotherapy, transplant, or diabetes)

YesNo

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.

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.

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.