Question

Response options

Do you have a fever?

Yes/No

Is your fever getting better or worse?

Better/Worse

Describe the severity of your fever?

Line number from 0 to 10

Select your current temperature

Line number from 35 to 40 degrees

Do you have a persistent dry cough?

Yes/No

Rate the severity of your cough?

Line number from 0 to 10

Is your cough getting better or worse?

Better/Worse

Do you cough mucus from your lungs?

Yes/No

Please rate the severity of your mucus of phlegm

Line number from 0 to 10

Is your mucus improving or getting worse?

Better/Worse

Do you have a sore throat?

Yes/No

Do you have a newly acquired shortness of breath?

Yes/No

Do you feel abnormally fatigued?

Yes/No

Are your joints unusually painful?

Yes/No

Is your skin unusually pale or clammy?

Yes/No

Do you have any of these symptoms?

Headache, muscle pains, runny nose, nausea, vomiting or diarrhea, fatigue, loss of sense or smell, altered sense of taste, jaw pain, chest pain, feeling unusually cold, new pain which prevents walking

Yes/No

Infected with coronavirus 2019 before?

Yes/No