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COVID Clear Screening
Please fill out and submit this form when finished.
10
Questions
START
1
Date
Date
Month
Day
Year
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12
4
1
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Hour
00
10
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30
40
50
00
00
10
20
30
40
50
Minutes
AM
PM
PM
AM
PM
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2
Type of Screening
Client
Employee
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3
Name
*
This field is required.
Enter Your Full Name Below
First Name
Last Name
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4
Is your temperature > 99.5 F
*
This field is required.
YES
NO
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5
Have you had a cough that is new or different from the baseline of your chronic health condition?
*
This field is required.
YES
NO
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6
Have you experienced shortness of breath that is new or different from the baseline of your chronic health condition?
YES
NO
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7
Have you experienced new loss of taste or smell?
*
This field is required.
YES
NO
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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-19
No, I have not knowingly been exposed to someone currently diagnosed with COVID-19
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9
In the last 10 days, have you been diagnosed with COVID-19?
YES
NO
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10
Have you experienced any of the following new or worsening symptoms in the past 14-days unrelated to another diagnosed illness?
None
Fever or chills/Shaking chills
Cough
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
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11
Add to Home Screen
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