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Visitor Health Screening
Guthrie Mainstream Services
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* Indicates required question
Name of Visitor
*
Your answer
Contact Number
*
Your answer
Whom are you visiting?
*
Your answer
Purpose of visit?
*
Your answer
1. Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (check all that apply)
*
Fever (100.0 degrees F or greater)
Cough
Shortness of breath or difficulty breathing
Sore throat
New loss of taste or smell
Chills
Head or muscle aches
Nausea, diarrhea, vomiting
None of the above
Required
2. In the past 14 days, have you been in close proximity to anyone with the above symptoms or who has tested positive for COVID-19?
*
Yes
No
3. Have you received the COVID-19 Vaccination?
Yes
No
I don't want to disclose.
Clear selection
I understand I need to inform Guthrie Mainstream Services if I test positive for COVID-19, within 3 days of visiting a GMS facility.
*
I understand
Required
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