COVID-19 Health Screening Tool
Name *
Date *
MM
/
DD
/
YYYY
Time in *
Time
:
In the past 24 hours, have you experienced: *
Yes
No
Fever (felt feverish or above 100.4 F)
New or worsening cough
Shortness of breath
Sore throat
Diarrhea
Current Temperature (F)
In the Past 14 days, have you Had close contact with an individual diagnosed with COVID-19? *
Additional Comments
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