COVID-19 Screening Questionnaire

Can you answer “Yes” to any of the following statements?

1. I am in one of the following Vulnerable groups related to COVID-19
   1. Moderate to Severe Asthma
   2. Chronic Lung Disease
   3. Diabetes
   4. Serious Heart Condition
   5. Chronic Kidney Disease
   6. Chronic Liver Disease
   7. Age 65 or above
   8. Immunocompromised (including medications, cancer treatments, transplants, HIV)
2. I do not want to enter a public healthcare office/setting that possibly could expose me to the COVID-19 virus

Within the last 14 days-

1. I have tested positive for COVID-19
2. I have been in contact with someone that has tested positive for COVID-19
3. I have had a fever of 100.4 degrees or above
4. I have had trouble breathing or had shortness of breath
5. I have felt ill or sick
6. I have traveled on a commercial airline internationally