COVID-19 Wellness Declaration
Full Name
Room Number
Date
Health Screening
Have you experienced any of the following symptoms in the past 14 days?
Fever
Cough
Shortness of breath
Loss of taste or smell
Have you tested positive for COVID-19 in the past 14 days?
Yes
No
Have you been in close contact with a confirmed COVID-19 case in the last 14 days?
Yes
No
Other Comments
Signature