Coronavirus (COVID019) Illness Reporting Form

What symptoms have you experienced? *

Fever over 100.3

Dry cough

Body ache

Fatigue

Sore throat

Shortness of breath

No symptoms

Have you been tested for COVID-19? *

Yes

No

Pending appointment

If yes, Positive/Negative? *

Positive

Negative

Sought medical care? *

Yes

No

Pending appointment