Sick Questionnare | Kroll Medical

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Respiratory Symptom Input Tool

How are you feeling today?

First Name

Last Name

I have had a temperpature of over 100 degrees F in the last 48 hours

I have had cough, congestion and/or shortness of breath

I have been in close contact with a Covid-19 patient in the last 14 days

I am having chest pain.

I have personally had a COVID test within the past week.

Date

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!

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