GHA Visitor COVID-19 Screening Tool

GHA Visitor COVID-19 Screening Tool

Please complete the following information prior to picking up/dropping off your loved one or anytime when visiting a GHA site.
Visitor First Name
Visitor Last Name
First Name of Individual being visited or released for TL
Last Name of Individual being visited or released for TL
GHA Site*
In the past 10 days, have you been around anyone sick or that has been told they have COVID?*

YesNo
In the interest of protecting the health of those we serve, you may not visit at this time. Please notify manager.
Currently (today) or in the last 10 days, ANY of the following symptoms? (mark all that apply)

Allergy symptomsCold symptomsFever or feeling feverish (Chills or sweating)Headache or Sinus pain/pressureCongestion or Runny NoseCoughShortness of breath or trouble breathingChest Pain or Chest TightnessMuscle of Body AchesSore ThroatNausea or VomitingDiarrheaStomach pain/crampingFatigue (being more tired than normal)Loss of Taste or Loss of Smell
In the interest of protecting the health of those we serve, you may not visit at this time. Please notify manager.
Current Temperature Reading (if 99.5 or higher, considered abnormal)*
In the interest of protecting the health of those we serve, you may not visit at this time. Please notify manager.
Name of person completing this form

First NameLast Name
Today's date*

MonthDayYear
Date
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