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COVID-19 (Coronavirus) Questionnaire

  1. 1a. Are you 65 or older and been diagnosed with common COVID-19 comorbid conditions, such as: diabetes, obesity or high blood pressure?*

  2. 1b. Have you been fully vaccinated against COVID-19?

  3. 2. Have you traveled outside of the USA in the last 14 days?*

  4. 3. Have you traveled within the USA in the last 14 days?*

  5. 4. Have you been on a cruise ship in the last 14 days?*

  6. 5. Has a household member been in close contact with anyone who has traveled domestically or internationally in the last 14 days?*

  7. 6. Have you attended any events or gatherings with more than 100 people?*

  8. 7. Have you been in close contact with a person known to have the 2019 Novel Coronavirus?*

  9. 8. Have you and/or a household member been asked to self-quarantine?*

  10. 9. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?*

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  12. This field is not part of the form submission.