Covid 19 Daily Status Update Form

Records a patient's symptoms, recent travel, and contact details each day to help track their COVID-19 health status over time.

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Name

First Name

Last Name

Birth Date

Email

Phone Number

Have you had any of the following symptoms in the recent 48 hours?

Have you traveled 100 miles outside of your current area in the last 48 hours, or to any "High Risk" or densely populated metropolitan areas?

Yes No

Today Date

Signature

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