Drew University Daily Health Questionnaire

Drew University

Daily Health Questionnaire
Name*

First (Given) NameLast Name (Surname)
Risk
Email*
(Please use the email provided to you by the university i.e. @drew.edu. This sends the results to your email, enabling documentation.)
Cell Phone*

Area CodePhone Number
Affiliation*
In the past 2 days, have you had any of the following NEW symptoms that cannot be attributed to another medical condition or activity?
- Fever of 100F or higher
- New or worsening cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Nausea or vomiting
- Diarrhea
In the past 2 days, have you had any of the following NEW symptoms that cannot be attributed to another medical condition or activity?*

YesNo
Have you been in close contact (within 6 feet for more than 10 minutes) with anyone known or suspected to have COVID - 19 in the last 14 days?*

YesNo
Have you been recently tested for Covid-19 because you either have symptoms or were exposed to someone with Covid-19 and are waiting for results?*

YesNo
Have you tested positive for COVID-19 within the past 14 days?*

YesNo
Have you recently travelled from a COVID-19 state under New Jersey travel restriction within the past 14 days?*

YesNo
Date

YearMonthDay
DateHourMinutesAM/PM Option
I certify all the information provided is shared to the best of my ability.
Should be Empty: