Date (mm/dd/yyyy):
First Name:
Last Name:
Have you been in close contact with a confirmed case of COVID-19?:
Have you had a fever or felt feverish in the last 72 hours?:
Are you experiencing any respiratory symptoms including a runny nose; sore throat; cough or shortness of breath?:
Are you experiencing gastrointestinal symptoms such as nausea; vomiting or diarrhea?:
Are you experiencing any new muscle aches or chills?:
Have you experienced any new changes in taste or smell?:
Are you running a fever over 100 degrees?:
Have you traveled in the last 14 days (outside NH; VT; RI; CT; MA; or ME)?: