COVID-19 Health Risk Screening Form
Full Name
Date
Contact Number
Are you experiencing any of the following symptoms? (Check all that apply)
Fever
Cough
Shortness of breath
Loss of taste or smell
None of the above
Have you been in close contact with a confirmed or probable COVID-19 case in the past 14 days?
Yes
No
Have you traveled internationally in the past 14 days?
Yes
No
Additional Information