Workplace Health Screening Intake Form
Please complete this form to assist us in conducting your health screening.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Symptoms (if any)
Have you been in contact with anyone diagnosed with a contagious illness recently?
Yes
No
Do you have any pre-existing medical conditions?
Yes
No
If yes, please specify your medical conditions
Have you received a COVID-19 vaccination?
Yes
No
Date of last COVID-19 vaccination
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: