COVID-19 Health Self-Assessment
Personal Information
Full Name
Date
Email Address
Phone Number
Health Screening Questions
1. Are you experiencing any of the following symptoms: fever, cough, shortness of breath, sore throat, or loss of taste/smell?
Yes
No
2. Have you tested positive for COVID-19 in the past 10 days?
Yes
No
3. Are you waiting for the results of a COVID-19 test?
Yes
No
4. Have you had close contact with anyone who has tested positive for COVID-19 within the past 14 days?
Yes
No
5. Have you been advised to self-isolate or quarantine by a health authority?
Yes
No
Declaration
I confirm that the above information is accurate and complete.