COVID-19 Screening

1

Date

Hour

Minutes

2

Type of Screening

Client

Employee

3

Name* This field is required.Enter Your Full Name Below

First Name

Last Name

4

Is your temperature > 99.5 F* This field is required.

YESNO

5

Have you had a cough that is new or different from the baseline of your chronic health condition?* This field is required.

YESNO

6

Have you experienced shortness of breath that is new or different from the baseline of your chronic health condition?

YESNO

7

Have you experienced new loss of taste or smell?* This field is required.

YESNO

8

In the last 14 days, have you knowingly been exposed to someone currently diagnosed with COVID-19? (Exposure = less than 6 ft for greater than 15 minutes)?* This field is required.

Yes, I have knowingly been exposed to someone diagnosed with COVID-19No, I have not knowingly been exposed to someone currently diagnosed with COVID-19

9

In the last 10 days, have you been diagnosed with COVID-19?

YESNO

11

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