Retail Store Customer COVID-19 Symptom Screening Sheet
Customer Information
Full Name
Date
Phone Number
Time In
Symptom Check (Check all that apply)
Symptom
Present?
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Exposure & Risk Questions
In the last 14 days, have you had close contact with anyone diagnosed with COVID-19?
In the last 14 days, have you traveled internationally?
In the last 14 days, have you attended any gatherings of more than 10 people?
Comments / Notes