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*If the client is a minor, this form must be filled out and signed by the minor’s Parent or Guardian.

COVID-19 Screening
Questionnaire
1. Have you been diagnosed with COVID-19?
YES NO

If Yes, what date were you diagnosed?

Have you been fever free without the use of medication that reduces
fevers and quarantined yourself for a minimum of 14 days?

YES NO

2. Have you come into close contact with someone who has a laboratory
confirmed COVID-19 (Coronavirus) diagnosis within the last 14 days?
YES NO

3 Do you currently have (or have had in the last 14 days) a fever (greater than
. 100.4 °F or 38.0 °C)?
YES NO

4. Do you have (or have had in the last 14 days) symptoms of lower respiratory
illness such as cough, shortness of breath or difficulty breathing? Or any of the
following, fever, chills, muscle pain, headache, sore throat, or new loss of taste
or smell? YES NO

Client Name: Date:

Signature: