Note: Please complete within four (4) hours of your scheduled visit, if possible. Otherwise, you must immediately complete upon arrival. * All Questions Required Full Name * Phone Number (mobile or home) * Probation Officer's Name * Scheduled Time for Office Visit * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) Fever (100.4 degrees Fahrenheit/37.8 degrees Celsius or greater as measured by an oral thermometer) * Yes No Cough * Yes No Shortness of breath or difficulty breathing * Yes No Sore throat * Yes No New loss of taste or smell * Yes No Chills * Yes No Head or muscle aches * Yes No Nausea, diarrhea, vomiting * Yes No In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? * Yes No In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? * Yes No In the past 14 days, have you been tested for COVID-19 and are waiting for test results? * Yes No In the past 14 days, have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms? * Yes No In the past 14 days, have you been on a commercial flight or traveled outside of the United States? * Yes No In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States? * Yes No
