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Covid + Questionnaire

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What is your name? *

What is your date of birth? *

What is your address? *

What is your phone number? *

Where are you employed at or attend school? *

When did you test positive for Covid? *

When did your symptoms start? *

I have experienced the following symptoms (check all that apply): *

I did not have any symptoms (asymptomatic)

Fever greater than 100.4

Subjected fever (felt feverish)

Chills

Sudden feeling of cold with shivering

Muscle Aches

Runny nose

Sore throat

Cough (new onset/worsening of chronic cough

Wheezing

Shortness of breath

Chest pain

Nausea or vomiting

Headache

Fatigue

Abdominal pain

Diarrhea

New olfactory and taste disorders

Difficulty breathing

Conjunctivitis

Confusion or change in mental status

Persistent pain or pressure in the chest

Pale, gray or blue colored skin, lips, nail beds

Inability to wake or stay awake

Other (please specify)

Were you hospitalized for your COVID infection? *

Yes - please list dates on "Other" line

Other (please specify)

How many people live in your household? *

Please include the names of other household members or close contacts who have tested positive for COVID within the last 14 days.

Have you traveled anywhere in the last 14 days? If yes, please list your travel destinations and dates.

Do you know where you were exposed to COVID? (If yes, please explain.) *

Yes

Other (please specify)

If you need documentation of your positive COVID status for work or school, please provide us with an email address:

Are you vaccinated for COVID? *

Yes

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Contact Us

If you have any questions or need to express a concern, please do so by filling out our contact form. Please choose a department and we will be sure that the appropriate staff will be in touch with you shortly.

Ashland County
Health Department
1763 State Route 60
Ashland, OH 44805
Phone: (419) 282-4231

SATISFACTION SURVEY

Office Hours:
Monday - Friday: 8:00am - 4:00pm

Emergency Contacts