First Name: Last Name:
Phone
Temperature (in °F)
Visitor or Employee? VisitorEmployee
Note: The information above will be used only to determine risk and your ability to work or visit. Your personal answers to this questionnaire are confidential and will be stored in your medical file.
Have you had any of the following new symptoms in the last seven (7) days: fever or chills, cough (either new, or different than your usual cough), sore throat, shortness of breath, or any other flu-like symptoms? YesNo
Have you been within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period who has tested positive for COVID-19 or has suspected COVID-19? YesNo
If the answer is “yes” to any of the questions or your temperature exceeds 100.4° F, you may not return to work or visit the suite until you satisfy the following…
10 days since symptoms first appeared and
24 hours with no fever without the use of fever-reducing medications and
Other symptoms of COVID-19 are improving
If asymptomatic, but have been in contact with confirmed or suspected COVID-19, you may return after a 14 day quarantine or a negative test result.
