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

    [group IsolationCond] Are you following recommended precautions and in-home isolation? YesNo [/group]

    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

    [group SymptomsCond] Are you experiencing shortness of breath? YesNo [/group]

    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

    [group low-risk]

    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.

    [/group]
    [group medium-risk]

    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.

    [/group]
    [group high-risk]

    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.

    [/group]