COVID Screening Questionnaire (Portuguese)

This is the Portuguese page for the COVID Screening Questionnaire. Click below for other languages:

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Portuguese

      

What is your full name?

      

What is your date of birth?

      

Answer option for these questions: Yes or No

 

Travel Screening

      

Have you traveled outside the US in the last 30 days?

 

Symptom Screening

      

Have you had a fever or felt feverish in the past 24 hours?

      

Have you had contact with a known or suspected case of COVID-19?

      

Do you have trouble breathing or a new cough?

      

Are you having nausea, vomiting, or diarrhea?

      

Do you have a new rash?

 

      

Do you have any of the following new symptoms?

      

Sore throat

      

Muscle Aches

      

Severe Dizziness/Fainting

      

Anosmia (Change in Smell)

      

Chest Pain

      

Nasal Congestion

      

None