Senior Living Facility Food Server Health Form
Personal Information
Full Name
Date of Birth
Position
Facility Name
Health Screening
Have you had a fever in the last 14 days?
No
Yes
Do you currently have any of the following symptoms? (cough, sore throat, nausea, vomiting, diarrhea, etc.)
No
Yes
Have you been diagnosed with any infectious illness in the past month?
No
Yes
Have you been in close contact with anyone who has had a communicable disease in the past month?
No
Yes
Medical History
Allergies
Current Medications
Work Restrictions
Signature
Signature
Date