This is a test: Corona Virus (COVID-19) Symptoms Self-Report

Corona Virus (COVID-19) Symptoms Self-Report Form

If you currently have symptoms of COVID-19, please fill out the appropriate form below. If your information indicates that you need follow-up, the health department will contact you directly. Your information will not be shared with others, but will be used to help us track the spread of this disease. Do you want to proceed? *

Have you been exposed to someone who tested positive for COVID? *

Were you exposed in a public or private place? *

Name of Location where exposure took place (if known) *

Where do you live? *

Your Sex *

What is your Age? *

What are your symptoms right now? required *

If other, please specify:

How severe are your symptoms? (1 = mild and 10 = severe) *

Do you have any pre-existing medical conditions such as heart disease, diabetes, or lung disease? *

Are you immuno-compromised? *

When did your symptoms begin? *

Your Full Name *

Your Home Address: House, Road, Street Name *

Your Home Address: Thana *

Your Home Address: City or Area *

Your Phone Number *

Your Email *

Anything else we should know about your symptoms?

Follow-up If you reported symptoms and you experienced worsening symptoms, please contact your primary care provider. Thank you for reporting your symptoms through our online form. Someone from the Local Public Health Department will be in contact with you.