COVID-19 Screening Form

Purpose: This form is intended to help healthcare providers screen individuals for symptoms or exposure related to COVID-19 prior to receiving care. Please complete all sections accurately to help ensure the safety of staff and patients.

Participant Information

• Full Name: {fullName}
• Date of Birth: {dateOfBirth}
• Phone Number: {phoneNumber}
• Email Address: {email}
• Date of Screening: {screeningDate}

Symptoms Checklist

Have you experienced any of the following symptoms in the past 14 days?

{#symptoms}

• {symptom}

{/symptoms}

Note: Symptoms may include fever, cough, shortness of breath, fatigue, muscle/body aches, loss of taste or smell, sore throat, congestion, nausea, or diarrhea.

Exposure History

• Have you tested positive for COVID-19 in the past 14 days? {testedPositive}
• Have you had close contact with someone who has tested positive for COVID-19 in the past 14 days? {hadContact}

Vaccination Information

• Have you been vaccinated against COVID-19?

{#isVaccinated}

• Date of Last Dose: {lastDoseDate}
• Vaccine Type: {vaccineType}

{/isVaccinated}

Travel History

• Have you traveled internationally in the last 14 days?

{#internationalTravel}

• Country Visited: {countryVisited}
• Return Date: {returnDate}

{/internationalTravel}

Screening Outcome

Result: {screeningResult}

{#recommendations}

• {recommendationText}

{/recommendations}

Signature

Name of Screener: {screenerName}

Signature: {screenerSignature}

Date: {signatureDate}