COVID-19 Daily Health Check
Full Name
Date
In the past 24 hours, have you experienced any of the following symptoms (not related to a known pre-existing condition)?
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Have you tested positive for COVID-19 in the past 10 days?
Yes
No
Have you been in close contact with anyone who has tested positive for COVID-19 in the past 10 days?
Yes
No