(if done by another family member)
Please choose YES or NO for each of the following questions
Do you have any symptoms of: Dry cough? Shortness of breath? Difficulty breathing? Sore throat, fever, or any flu like Symptoms in the last 2 weeks?
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
Have you had any changes to your health, or have you been hospitalized in the last year?
To the best of your knowledge are you considered in good health?