Arrival and Health Review Form

Name

First NameLast Name

Arrival Date & Time

Date

Hour MinutesAM/PM Option

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

COVID-19 Symptoms

Cough

Loss of smell

Loss of taste

Shortness of breath

fatigue

fever

chills

runny nose

diarrhea

headache

sore throat

Do you currently have any of the following symptoms listed above?

YesNo

If yes, what are the symptoms you're currently experiencing?

What is your current temperature?

Did you come from a location where there a lot of COVID-19 cases?

YesNo

Are you living with someone who are experiencing COVID-19 symptoms?

YesNo

Are you living with someone who tested positive for COVID-19?

YesNo

Have you been in close contact with someone who has COVID-10 or suspected COVID-19 in the the last 2 weeks?

YesNo

Have you tested positive for COVID-19?

YesNo

If yes, when did you tested negative for COVID-19?

Past 14 daysPast 7 daysPast 3 daysOther

Signature

Date Signed

Date