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COVID-19 (Coronavirus) Questionnaire
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Summons Barcode Number
1. Are you 65 or older and been diagnosed with common COVID-19 comorbid conditions, such as: diabetes, obesity or high blood pressure?
2. Have you traveled outside of the USA in the last 14 days?
3. Have you traveled within the USA in the last 14 days?
4. Have you been on a cruise ship in the last 14 days?
5. Has a household member been in close contact with anyone who has traveled domestically or internationally in the last 14 days?
6. Have you attended any events or gatherings with more than 100 people?
7. Have you been in close contact with a person known to have the 2019 Novel Coronavirus?
8. Have you and/or a household member been asked to self-quarantine?
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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