Pre-Date Questions
- Do you have a fever of 100° or higher, or have you felt feverish recently?
- Do you have a cough?
- Are you having shortness of breath or any difficulty breathing?
- Do you have chills or repeated shaking with chills?
- Do you have any muscle pain?
- Do you have any recent onset of headache or sore throat?
- Do you have any other flu-like symptoms?
- Do you have any recent loss of taste or smell?
- Have you experienced any recent GI upset or diarrhea?
- To your knowledge, have you been within six feet, for more than five minutes, of anyone who has been confirmed to be COVID-19 positive, or is being tested for COVID-19?
- Have you been tested for COVID-19? If yes, what was the result?
- Have you traveled outside of your normal routine in the past two weeks?
- Have you socialized in any groups of more than five people?
- Have you been intimate with or spent prolonged time around anyone in the last two weeks who would answer yes to any of the above?
Exposure Risk Factors
- Are you and your housemates working from home? If no:
- Does your job have you interacting with more than five co-workers on a regular basis?
- Is your job customer facing?
- Are customers required to wear masks?
- Are employees required to wear masks?
- Do you wear gloves when interacting with customers?
- How frequently do you wash/sanitize your hands while at work?
- Is there a partition between you and customers?
- Is your employer testing employees for fever before each shift?
- Do you feel that your employer is taking this pandemic seriously?
- How frequently are you and your housemates leaving the home for non-essential reasons?
- Do you wear a mask while in public? Do your housemates?
- Have you or your housemates been visiting any public gathering spaces, such as restaurants, gyms, beaches, or the zoo?
- How many people are in your isolation bubble which you interact with weekly? This includes relatives, children’s playdates and people who work in your house.
- If you have children, do they attend day care, school or any other kind of kids group?
- Do you allow your children to use communal play equipment