COVID-19 Daily Wellness Assessment
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We care for your safety, wellness, and health. Please answer the questions below:
Please select below:
I'm an employee
I'm a visitor
I'm a staff
Other
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
ID No.
Department
Were you told by health care professionals to self-quarantine or self-isolate?
Yes
No
Did you had face-to-face contact to someone for 10 minutes who is suspected to have COVID-19 in the last 14 days?
Yes
No
Did you travel to a location with a travel warning as CDC in the last 14 days?
Yes
No
Are you experiencing any of the following symptoms in the last 48 hours?
Yes
No
Remarks
Fever (over 100.3F)
Loss of smell or taste
Shortness of breath
Cough
Diarrhea
Nausea and vomiting
Loss of appetite
Headache
Sore throat
Chills
Muscle weakness
Restlessness
Conjunctivitis
Comments, feedback, or suggestions
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