Do you currently or in the last 14 days have had a fever or temperature over 100.4F? * YesNo Do you currently or in the last 14 days have you experienced shortness of breath or had trouble breathing? * YesNo Do you currently or in the last 14 days have you had a dry cough? * YesNo Do you currently or in the last 14 days have you had a sore throat? * YesNo In the last 14 days have you been in contact with someone who has tested positive for COVID‐19? * YesNo In the last 14 days have you tested positive for COVID‐19? * YesNo In the last 14 days have you been tested for COVID‐19 and are awaiting results? * YesNo Have you traveled outside the United States by air or cruise ship in the past 14 days? * YesNo I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. Full Name * Date *