COVID Pass (non EHC) : Survey

COVID Pass (non EHC)

Please answer yes or no for all symptoms and enter all required fields

Have you experienced any of the following symptoms in the last 24 hours?
Fever greater than or equal to 100F Fever greater than or equal to 100F	Yes No
Shaking or chills Shaking or chills	Yes No
Loss of taste or smell Loss of taste or smell	Yes No

Do you have new or worsened:
cough cough	Yes No
shortness of breath shortness of breath	Yes No
sore throat or congestion sore throat or congestion	Yes No
muscle aches muscle aches	Yes No
headache headache	Yes No
nausea/vomiting/diarrhea nausea/vomiting/diarrhea	Yes No
rash rash	Yes No

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								First Name:*
								
								Last Name:*
								Last Name:*
								
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