Do you have fever above 100.4 F *

A cough *

Shortness of breath *

Loss of taste of smell *

Any flu like symptoms such as upset stomach, headache, fatigue or pains *

Have you been in contact with someone who has tested positive for Covid-19 in the last 14 days *

Have you been tested for Covid-19 in last 14 days *

What is the result of the testing *

Have you travelled anywhere during the last 14 days? *

Are you over 60? *

Do you have any heart disease, lung disease, kidney disease, diabetes or any other auto immune disease? *