1.Do you have any of these symptoms that are not caused by another condition?:
Fever or chillsShortness of breath or difficulty breathinFatigueMuscle or body achesHeadacheRecent loss of taste or smellSore throatCongestionNausea or vomitingNone Of These
2. Within the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms? Contact is being 6 feet (2 meters) or closer for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on).:
3. Have you had a positive COVID-19 test for active virus in the past 10 days?:
4. Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?
Please Put Your name In Box As Signature
2838 Webb Ave, Bronx, NY 10468, USA