Section 1 of 1 in this document
ADA COVID-19 Risk Assessment form
First Name
*
Last Name
*
Today's Date
*
Do you have fever or have you felt hot or feverish recently (14-21 days)?
No
Yes
Are you having shortness of breath or other difficulties breathing?
No
Yes
Do you have a cough?
No
Yes
Are other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes
No
Have you experienced recent loss of taste or smell?
No
Yes
Are you in contact with any confirmed COVID-19 positive patients?
No
Yes
Is your age over 60?
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
No
Yes
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
No
Yes
disregard this