COVID-19 Daily Wellness Assessment
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
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.
Format: (000) 000-0000.
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?
Rows
Yes
No
Remarks
Fever (over 100.3F)
1
2
Loss of smell or taste
3
4
Shortness of breath
5
6
Cough
7
8
Diarrhea
9
10
Nausea and vomiting
11
12
Loss of appetite
13
14
Headache
15
16
Sore throat
17
18
Chills
19
20
Muscle weakness
21
22
Restlessness
23
24
Conjunctivitis
25
26
Comments, feedback, or suggestions
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: