COVID-19 Facility Screening Checklist
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Name *
Purpose of Visit *
Date & Time In *
MM
/
DD
/
YYYY
Time
:
Current Temperature In the past 24 hours *
Have you experienced Fever in past 24 hours *
Felt feverish or above 100.4° F
Have you experienced *
Yes
No
New or worsening cough
Shortness of breath
Sore throat
Vomiting or Diarrhea
Chills
Muscle pain
New loss of taste or smell
Pink Eye or Eye Infection
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