Covid-19 Daily Health Checklist
Family, Adult & Child Therapies (FACT)
Today's Date
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1
Name
First Name
Last Name
Do you have a fever (temperature over 100.3F) without having taken any fever reducing medications?
Yes
No
Do you have a cough?
Yes
No
Do you have shortness of breath?
Yes
No
Do you have chills or muscle aches?
Yes
No
Have you experienced any gastrointestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite?
Yes
No
Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19?
Yes
No
Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?
Yes
No
By entering my initials below, I certify to the answers in the above questions. At any time I start showing these symptoms, I will as a staff member, inform my employer immediately and as the client inform Family, Adult & Child Therapies (FACT).
INITIAL HERE
*
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