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Connect With A Counselor
Advocacy
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The Community Center
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Painted Brain | COVID-19 Self-Reporting Checklist
We're bridging communities and changing the conversation about mental illness using arts and media.
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COVID-19 Self-Reporting Checklist
Date
First Name
*
Last Name
*
Email
*
Confirm Email
Do you have a fever? (Temperature over 100.4˚ without having taken any fever-reducing medications)
*
Yes
No
Loss of smell or taste?
*
Yes
No
Muscle aches?
*
Yes
No
Sore throat?
*
Yes
No
Cough?
*
Yes
No
Shortness of breath?
*
Yes
No
Chills?
*
Yes
No
Headache?
*
Yes
No
Have you experienced any nausea, vomiting, diarrhea, or loss of appetite?
*
Yes
No
Have you or anyone you've been in close contact with been diagnosed with COVID-19, or been placed in quarantine due to possible contact?
*
Yes
No
Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?
*
Yes
No
Have you returned from traveling over 800 miles from your home in the past month?
*
Yes
No
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