Please enable JavaScript in your browser to complete this form.Name of Family *Last NameCOVID-19 Pre-ScreeningPlease read and respond honestly to each questionIn the last 14 days has anyone in your family been exposed to any persons with confirmed COVID-19 by lab test or been in contact with anyone exhibiting COVID-19 symptoms? *YESNOIn the last 14 days has anyone in your household been sick or been around anyone that has been sick? *YESNOIn the last 14 days has anyone in your family had any of the symptoms listed below? *YESNO●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 ●DiarrheaDoes anyone in your family have a temperature above 100.4° *YESNODateSubmit