Please provide the information below

Celsius   Fahrenheit


When did this start?
Date and time required
New Cough
Yes   No
New Shortness of Breath
Yes   No
Sore Throat
Yes   No
Loss of a sense of taste or smell
Yes   No
Feeling achy
Yes   No
Yes   No
Yes   No
Exposure level
When? (date)
Have you been in contact with someone with known or suspected coronavirus (COVID-19)?
Yes   No

Please note the following:

This form is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

If you have a general question about COVID-19, please call our hotline at 646-697-4000.

Education - Prevent the spread of colds, flu and COVID-19

Everyone should:
Wash your hands often with soap and water for at least 20 seconds, especially if you have been in a public place, or after blowing your nose, coughing, sneezing, and before you eat. Cover your cough and sneezes with the inside of your elbow or with a tissue, and discard the tissue in a closed container. Clean frequently touched surfaces and objects. Avoid close contact with people who are sick. Keep a distance of at least 6 feet to help slow the spread of COVID-19.

For people who are sick - stay home:
If you have a fever, stay home for at least 72 hours after your fever is gone without the use of fever-reducing medicines, such as acetaminophen. Keep sick household members away from others. If you have a separate room, that is best. Use soap and water, a bleach and-water solution, or EPA-approved household products to clean high-touch surfaces in your “sick room,” bathroom, and common areas. You can make your own cleanser with a mixture of 1/3 cup of liquid unscented chlorine bleach and 5 gallons of water. Avoid sharing personal items. Anyone with severe illness or at high risk for complications should talk to their healthcare provider for more information.

Visit the Department of Health Site »