Patient Name Date In the last 2 WEEKS have you experienced: Fever (100.4+ degrees) YesNo Dry Cough YesNo Productive Cough YesNo Difficulty breathing YesNo Altered taste YesNo Altered smell YesNo Sore Throat YesNo Fatigue/Muscle Pain/Chills YesNo Additional Questions: Are you considered an immunocompromised or High-Risk individual? YesNo Have you previously been diagnosed as having COVID-19? YesNo Been in close contact with any who has diagnosed or suspected COVID-19? YesNo Traveled outside Washington in the last 2 weeks? YesNo Been on a plane in the last 2 weeks? YesNo Additional Information
