Infectious Disease Exposure History Form
Full Name
Date of Birth
Contact Number
Email
Address
Have you been exposed to any known infectious diseases in the past 14 days?
Yes
No
If yes, specify the disease(s) and exposure date(s)
Are you currently experiencing any of the following symptoms? (Check all that apply)
Fever
Cough
Sore Throat
Shortness of Breath
None
Additional Information
Date
Signature