Health Symptoms Questionnaire

Log temperature, respiratory symptoms, recent contacts and travel for everyone entering a workplace. It suits companies, retailers and building managers running daily entrance checks. A consent box for data handling is built in.

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Date*

Full name*

Nombre

Apellido

Age

Gender*

Female Male Non-binary Prefer not to say

Company*

Site or department

Body temperature*

Are you experiencing any of these symptoms?*

Fever Cough Runny nose Sore throat Difficulty breathing Loss of smell or taste None of these

Have you worked with or stayed close to a confirmed COVID-19 case?*

Yes No Not sure

In the past two weeks, have you had contact with anyone with fever, cough, cold or a sore throat?*

Yes No Not sure

Have you travelled outside the country in the past 14 days?*

Yes No

If yes, state where

Have you travelled to another part of the metropolitan area besides where you live?*

Yes No

If yes, state where

I declare that the information given is true and I understand it will be used only for health checks on entry to the premises.

Consent to the handling of this data*

I give my consent I do not give my consent

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