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 a fever of 100 degrees or higher within the last 72 hours?*yesnoHave you developed a cough?*yesnoHave you experienced shortness of breath?*yesnoHave you been in contact with someone who has may have Covid-19 or who has been asked to self-quarantine?*yesnoAre you a healthcare provider?*yesno This iframe contains the logic required to handle Ajax powered Gravity Forms.