COVID Questionnaire do or do not , there is no try First Name Last Name Email Have you had any known exposure to a COVID-19 positive person in the last 14 days? Yes No Has anyone in your household had COVID-19? Yes No If anyone in your household has had covid-19 please provide when this occurred What is your occupation? Is your occupation a medical risk? (Example- Registered Nurse, Physician, Caring for COVID-19 patients, Grocery Store Clerk, Delivery persons, etc..) Yes No Have you had an organ transplants? Yes No Are you on steroid medications or chemotherapy? Yes No Do you have diabetes, COPD, asthma, or cancer? Yes No Have you traveled in the past 14 days outside of New Jersey or any air travel? Yes No If yes, when did you return? Have you had any COVID-19 virus or antibody testing? Yes No If yes, please clarify results: Have you been vaccinated for COVID-19? Yes No If vaccinated provide 1st shot date If vaccinated provide 2nd shot date Have you traveled in the past 14 days to regions affected by COVID-19 or any air travel? Yes No In the past 2-14 days, have you had any of the following symptoms? Choose all that apply Cough Trouble Breathing Shortness of breath Severe wheezing Fever Chills Repeated shaking with chills Muscle pain Headache Sore Throat Loss of Smell or taste or change in taste We will NEVER rent or sell your information under any circumstances. Please be advised that communications via our website or e-mail are not encrypted or sent through a secured connection. Therefore, by sending information to us electronically, understand that there is a risk of your personal information being subjected to unauthorized use by outside parties. If you have any questions or concerns, please feel free to contact us at (973) 559-5231. If you receive an 'Unsuccessful Process' notice and are unable to submit your information when clicking the 'Submit' button below this is most likely due to a browser being out of date and no longer supported. Please try submitting your information in a different browser or by updating the browser you are currently using. We apologize for any inconvenience.