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Gender*
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Do you have a regular family doctor*
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Medical problems
Medications
Allergies
Cough *
Fever 38 or greater *
Shortness of breath or chest discomfort*
Runny Nose*
Vomiting*
Diarrhea*
Abdominal Pain*
Rash*
Eye Discharge*
Travel in last 14 days outside of Durham*
Contact with person diagnosed positive with COVID 19 or other communicable disease in last 14 days*
Have you been discharged from hospital in the last 14 days*
Do you smoke?*
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