COVID-19 Screening Health Questionnaire
Please respond to each of the following questions truthfully.
- 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
- 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?
- In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?
- Have you been tested for COVID-19 and are waiting to receive test results?
- 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
- In the past 14 days, have you been on a commercial flight or traveled outside of The US
- 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
I hereby certify that the responses provided above are true and accurate to the best of my
Signature: ______________________________________ Date: ____________
Access to facility (circle one): Approved Denied