YRMC

Name:


Cell Phone Carrier:


Phone Number:


1.- Within the past 10 days have you had a positive COVID test?



2.-Within the past 24 hours have you had any of the following symptoms: Fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle aches, body aches, headache, new lost of taste or smell, sore throat, nausea, vomiting or diarrhea?



3.- Have you had a temperature of 100.0F or above within the last 24 hours?



**I certify by submitting this survey that these answers are true based on the best of my knowledge.**


Copyright © 2021 Yuma Regional Medical Center. All rights reserved.