Curbside Questionnaire Curbside Questionnaire Name * Name First First Last Last Phone * Email * Have you or anyone in your household in the last 21 days had any of the following symptoms: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? * Yes No Have you or anyone in your household been tested for COVID-19? * Yes No Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19? * Yes No Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? * Yes No To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? * Yes No Captcha Submit If you are human, leave this field blank.
