COVID-19 Screening Questions

Have you tested positive for COVID-19?
Have you had contact or provided care for anyone with confirmed COVID-19 in the last 14 days?
Do you live in or work at an assisted living facility?
Are you currently experiencing or have you experienced any of the following symptoms in the last 14 days?
  • Fever or Chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.