Fighting COVID 19 – Wellness  Assessment Questionnaire

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

Disclaimer:  Use of this form is at your own risk including the addition and modification of any fields where necessary.

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