VSTC Daily Admittance Form

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Name *

Date of Birth *

YYYY

Phone number *

Have you been diagnosed with Covid-19 within the past 14 days? *

yes

Have you had close contact with or cared for someone who has tested positive for covid-19 within the past 14 days? *

yes

Have you been in close contact with a suspected case of covid-19 within the past 14 days? *

Yes

Have you experienced any of he following symptoms in the last 14 days? *

yes

Fever or chills

Dry cough

Difficulty breathing or shortness of breath

Fatigue

Muscle or body aches

Sore throat

Headache

Congestion or runny nose

Nausea or vomiting

Diarrhea

New loss of taste or smell

Signature *

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