Mental Health and Infectious Disease Screening Questionnaire Form
Please complete this screening questionnaire to help us assess your general well-being and potential exposure risks. All responses are confidential and used solely for screening purposes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Have you experienced any of the following symptoms in the past 14 days?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
In the past 14 days, have you had close contact with anyone diagnosed with an infectious disease?
*
Yes
No
Not sure
Have you traveled internationally in the last 30 days?
*
Yes
No
Are you currently feeling overwhelmed, anxious, or experiencing mood changes?
*
Yes
No
Prefer not to say
How would you rate your general mood over the past two weeks?
*
1
2
3
4
5
Have you had difficulty sleeping or changes in your sleep pattern recently?
Yes
No
Is there anything else you would like to share regarding your current health or well-being?
Submit Screening
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