COVID-19 screening form for Fayetteville Diagnostic Clinic COVID-19 screening form for Fayetteville Diagnostic Clinic Name* First Last Date of birth* Phone*Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish” or had a temperature of 100.4 F or greater?*yesnoHave you developed a cough?*yesnoHave you experienced shortness of breath?*yesnoDo you have any of the following symptoms? (Please mark all that apply)CoughShortness of breath or chest tightnessSore throatNasal congestion or runny noseBody achesLoss of taste and/or smellDiarrheaVomitingFever/chills/sweatsHave you been in contact with someone who has/ may have Covid-19 or who has been asked to self-quarantine?*yesnoHave you been tested for COVID-19?*yesnoAre you a healthcare provider?*yesnoCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.