Health screening
COVID-19 health questionnaire (Please answer all questions, honestly. Your temp will be taken on site before your appointment.)
* Required
First and Last name
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
Have you been asked to self isolate or quarantine by a doctor or local public health official in the last 14 days?
*
Yes
No
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath, or other respiratory problem)?
*
Yes
No
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
*
Yes
No
Have you recently taken or are currently awaiting results on a COVID-19 test?
*
Yes
No
If yes to any of the above questions, please explain.
Your answer
Temp (to be completed by staff)
Your answer
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