Health Questionnaire Form

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Health Questionnaire

Name:__________________________________________             Mobile#_____________________________                                                                       


                                               PRE-PRODUCTION       PRODUCTION DAY

                                                                                                         Date:____________        Date:____________

Do you/they have a fever or have you/they felt hot or feverish
recently (14-21 days)?                                                                           Yes     No                         Yes    No

Are you/they having shortness of breath or other difficulties
breathing?                                                                                              Yes     No                         Yes    No

Do you/they have a cough?                                                                   Yes     No                         Yes    No

Any other flu-like symptoms, such as gastrointestinal upset,
headache or fatigue?                                                                             Yes     No                         Yes    No

Are you in contact with any confirmed COVID-19 positive
patients? People who are well but who have a sick family
member at home with COVID-19 should consider a 14 day
quarantine.                                                                                             Yes     No                        Yes    No                              

Any new unexplained muscle aches?                                                    Yes     No                        Yes    No

Do you/they have heart disease, lung disease, kidney
disease, diabetes or any auto-immune disorders?                                  Yes     No                        Yes    No

Have you/they traveled in the past 14 days to any regions
affected by COVID-19 (as relevant to your location)?                          Yes    No                         Yes    No            


Positive responses to any of these questions would likely indicate a deeper discussion with the employer before proceeding to set location.

*For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.

**CDC guidance on COVID-19:  including Self-check your symptoms, Should you get testedCloth Face Coverings

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