Food Handler Medical Screening Form
Complete this Food Handler Medical Screening Form before starting or returning to food-service work. Please answer all questions accurately.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any of the following symptoms in the past 48 hours? (Select all that apply)
*
Vomiting
Diarrhea
Fever
Sore throat with fever
None of the above
In the last 14 days, have you been diagnosed with or exposed to any contagious illness (such as norovirus, hepatitis A, salmonella, or E. coli)?
*
Yes
No
Are you currently restricted from any work activities due to a medical condition?
*
Yes
No
If yes, please describe any work activity restrictions.
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Screening
Should be Empty: