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Apex Solutions Rapid COVID19 QUESTIONNAIRE

Please fill out the following form to help us understand your current physical condition.

First Name

Email Address

Last Name

Date of Birth

Within the last 14 days, have you been in close contact (within 6ft of an infected person for at least 15 minutes) with a person confirmed with COVID-19?

No

Yes

Are you experiencing a new cough, difficulty breathing or shortness of breath?

No

Yes

If you have experienced a fever (temperature of 100.4 degrees Fahrenheit or higher), a new loss of smell and taste or vomiting or diarrhea or vomiting, please explain.

Initials

Today's Date

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

Thanks for submitting!