Sorry to hear you’re not feeling well. Question 1 of 6Q1. Please let us know your current status:I don’t feel well and tested positive for COVID-19I don’t feel well and am waiting for my COVID-19 test resultsI don’t feel well and am planning to get tested for COVID-19I don’t feel well, think it’s COVID-19, but testing not recommendedI don’t feel well but don’t think it’s COVID-19 Sorry to hear you’re not feeling well. Question 2 of 6Q2. How many days have you not been well?123456789101112131415More than 15 days Sorry to hear you’re not feeling well. Question 3 of 6Q3. What are your symptoms? Fever Coughing Shortness of Breath Aches & Pains Sore Throat Diarrhea Chills Fatigue No Taste or Smell Other Other symptom Sorry to hear you’re not feeling well. Question 4 of 6Q4. How many people have you been in contact with (within 6ft) since you’ve felt unwell?01 - 45 - 1011 - 2020+ Sorry to hear you’re not feeling well. Question 5 of 6Q5. Did you go anywhere over the past two days? See family/friends Doctor/Hospital Beach/Park Grocery/Drug Store Pickup food Work Other No, just stayed at home Work LocationNameStreetCityZip Code Please list the company, street, city and zip code of the work location you visited.Food LocationNameShopping CenterCityZip Code Please list the name, shopping center (if known), city and zip code of the food location you visited.Medical LocationMedical BuildingCityZip Code Please list the medical building, city and zip code of the doctors/hospitals you have been to.Family And Friends LocationStreetCityZip Code Please list the neighborhood city and zip code of the family and friends house you visited.Beach Park LocationBeach/ParkCityZip Code Please list the beach/park, city and zip code of the locations you have been to.Other LocationLocationStreetCityZip Code Please list the location name, neighborhood city and zip code you have been to.Grocery/Drug Store LocationStoreShopping CenterCityZip Code Please list the store name, shopping center (if known), city and zip code of the stores you have been to. Sorry to hear you’re not feeling well. Question 6 of 6Q6. Please enter the nearest intersection to your residence.Intersection Street 1 Intersection Street 2 Zip CodeCommentsThis field is for validation purposes and should be left unchanged. Exit Survey (Current survey will be cleared)