COVID-19 Screening Health Questionnaire

Please respond to each of the following questions truthfully.

Name: _____________________________________

  1. Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms.

  Yes         No        Fever (100.4 F or greater)

 Yes         No        Cough

 Yes         No         Shortness of breath or difficulty breathing

 Yes         No          Sore Throat

 Yes         No          New loss of taste or smell

 Yes         No          Chills

 Yes         No          Head or muscle aches

 Yes         No           Nausea, diarrhea, vomiting

  1. In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since you contact?

 Yes         No

  1.  In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

 Yes        No

  1.  Have you been tested for COVID-19 and are waiting to receive test results?

 Yes      No

  1.  Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms

 Yes       No

  1.  In the past 14 days, have you been on a commercial flight or traveled outside of The US

 Yes         No

  1.  In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside the US

Yes          No

 I hereby certify that the responses provided above are true and accurate to the best of my

 Knowledge.

 Signature: ______________________________________        Date: ____________

 Access to facility  (circle one):        Approved            Denied