COVID-19 Symptom Check for Hard of Hearing


COVID-19 Symptom Check

I am deaf or hard of hearing. I am using this card to communicate. 
I may need a certified sign language interpreter, captioning or other ways to communicate.

I have circled the best ways to communicate with you.

  • Interpreter
  • Text
  • Writing
  • Lip Read
  • Gesture
  • Assistive Listening Device

Quick Communication

  • Yes
  • No
  • Don't Know

This is my level of pain:

  • No Pain
  • Mild Pain
  • Moderate Pain
  • Severe Pain
  • Very Severe Pain 
  • Worst Possible Pain

These are my symptoms:

  • Fever
  • Cough
  • Shortness of Breath
  • Sore Throat
  • Lost Sense of Taste/Smell
  • Muscle Aches
  • Chills
  • Headache

Other symptoms I have:

I have had symptoms this many days:

I have had close contact with someone (within 6 feet) who has COVID-19:

  • Yes
  • No
  • Unsure