Name: _____________________________ Date: ___________ Name: _____________________________ Date: ___________

Address: ___________________________ Time: ___________ Address: ___________________________ Time: ___________

Contact # _____________________ Temp.: _____________ Contact # _____________________ Temp.: _____________

Please check the boxes if you are experiencing the following: Please check the boxes if you are experiencing the following:

Headache Headache
Fever Fever
Dizziness Dizziness
Sore Throat Sore Throat
Runny Nose Runny Nose
Cough Cough
Breathing Difficulty Breathing Difficulty
YES NO YES NO

Had contact with a COVID 19 patient for Had contact with a COVID 19 patient for
the past 10 days the past 10 days

Had contact with a possible COVID 19 Had contact with a possible COVID 19
carrier for the past 10 days carrier for the past 10 days

Had tested positive for COVID 19 Had tested positive for COVID 19

Name: _____________________________ Date: ___________ Name: _____________________________ Date: ___________

Address: ___________________________ Time: ___________ Address: ___________________________ Time: ___________

Contact # _____________________ Temp.: _____________ Contact # _____________________ Temp.: _____________

Please check the boxes if you are experiencing the following: Please check the boxes if you are experiencing the following:

Headache Headache
Fever Fever
Dizziness Dizziness
Sore Throat Sore Throat
Runny Nose Runny Nose
Cough Cough
Breathing Difficulty Breathing Difficulty
YES NO YES NO
Had contact with a COVID 19 patient for Had contact with a COVID 19 patient for
the past 10 days the past 10 days

Had contact with a possible COVID 19 Had contact with a possible COVID 19
carrier for the past 10 days carrier for the past 10 days

Had tested positive for COVID 19 Had tested positive for COVID 19