Health Screening Checklist

A short daily or pre-visit screening that captures symptoms, recent international travel and known exposure. Contact details and the date are logged so records can be traced later. Handy for clinics, schools and workplaces running entry checks.

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Full name

First Name

Last Name

Phone number

Date

Have you had any of these symptoms in the past 14 days? Select all that apply.

Fever Cough Shortness of breath Sore throat Loss of taste or smell Unusual fatigue None of these symptoms

Have you travelled internationally in the past 14 days?

Yes No

If yes, list the countries you visited.

Have you been in close contact with anyone who tested positive for COVID-19 in the past 14 days?

Yes No Not sure

Add any further comments or information.

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