Name First

Name Last

Medicaid CIN#

Are you experiencing… (select all that apply) Are you experiencing… (select all that apply) Are you experiencing… (select all that apply) Fever, chills or sweating Difficulty breathing (not severe) New or worsening cough Sore throat Aching throughout the body Vomiting or diarrhea Loss of smell or loss of taste None of the above

Do you have any of these conditions? (select all that apply) Do you have any of these conditions? (select all that apply) Asthma or chronic lung disease Pregnancy Diabetes with complications Kidney failure that needs dialysis Cirrhosis of the liver Weakened immune system Congestive heart failure Extreme obesity None of the above

In the last 14 days, have you traveled internationally? In the last 14 days, have you traveled internationally? YES NO

In the last 14 days, have you visited an area where COVID-19 is widespread? In the last 14 days, have you visited an area where COVID-19 is widespread? YES NO

Do you live in an area where COVID-19 is widespread? Do you live in an area where COVID-19 is widespread? YES NO

In the last 14 days, what was your exposure to others? In the last 14 days, what was your exposure to others? I live with someone that has COVID-19 I’ve had close contact with someone who has COVID-19 I’ve had no exposure

Do you live or work in a care facility? Do you live or work in a care facility? I live in a long-term care facility (including nursing homes and assisted living) I have worked in a hospital or other care facility in the past 14 days I plan to work in a hospital or other care facility for the next 14 days No, I don’t live or work in a care facility

If you have a thermometer, please take your temperature and submit it:

Do you have a primary care doctor? y/n/unsure Do you have a primary care doctor? y/n/unsure YES NO Unsure

Who is your primary care doctor? If you do not have one, write none

What is your phone number?

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Email Address