Covid-19 Test

Name

Age

E-mail

Have you been with someone COVID positive? Have you been with someone COVID positive? Yes No

Have you experienced fever? (temperatures higher than 38º C or 100.4º F) Have you experienced fever? (temperatures higher than 38º C or 100.4º F) Yes No

Are you experiencing headaches? Are you experiencing headaches? Yes No

Are you coughing? Are you coughing? Yes No

Are you experiencing throat aches? Are you experiencing throat aches? Yes No

Are you experiencing chest pain? Are you experiencing chest pain? Yes No

Are you experiencing breathing difficulty? Are you experiencing breathing difficulty? Yes No

Are you experiencing runny nose? Are you experiencing runny nose? Yes No