DACA Clinic Health Screening
Client/Volunteer Name/Nombre:
Volunteer Drop Down
Have you or anyone in your household tested positive for Covid-19 in the past 2 weeks or have pending results from a Covid-19 test?¿Usted o alguien de su hogar ha dado positivo en Covid-19 o estás esperando los resultados de una prueba de Covid-19? en las últimas 2 semanas? *
Have you or anyone in your household been exposed to someone who has tested positive for Covid-19 in the last two weeks?¿Usted o alguien de su hogar ha estado expuesto a alguien que ha dado positivo en Covid-19 en las últimas 2 semanas ? *
Do you have any of the following symptoms?¿tiene alguno de los siguientes síntomas? *
Required
Fever Check (if over 100.4 they must be sent home) Comprobación de la fiebre (si son más de 100.4 deben ser enviados a casa)
Health Screening completed by: *
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