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Fighting COVID 19 – Wellness Assessment Questionnaire
Signing this form indicates that you confirm that you are feeling well and that you do not have any of the following symptoms: Headache / high temperature/fever / cough / sore throat / loss of smell / loss of taste. Should you be suffering from any of these symptoms please either self-isolate at home or seek medical attention.
Signing this form also indicates that you confirm that that you have not recently been in contact with anyone who has tested positive for COVID-19.
Temperature | Passed test? | Feeling Well? | |||||
Date | Name | Temperature Reading | Yes | No | Yes | No | Signature |
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