DACA Clinic Health Screening

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Client/Volunteer Name/Nombre:

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Have you or anyone in your household tested positive for Covid-19 in the past 2 weeks or have pending results from a Covid-19 test?¿Usted o alguien de su hogar ha dado positivo en Covid-19 o estás esperando los resultados de una prueba de Covid-19? en las últimas 2 semanas? *

Yes

Other:

Have you or anyone in your household been exposed to someone who has tested positive for Covid-19 in the last two weeks?¿Usted o alguien de su hogar ha estado expuesto a alguien que ha dado positivo en Covid-19 en las últimas 2 semanas ? *

Yes

Other:

Do you have any of the following symptoms?¿tiene alguno de los siguientes síntomas? *

cough/la tos

fever/la fiebre

sore throat/el dolor de garganta

loss of taste or smell/pérdida de sabor u olor

headache/el dolor de cabeza

none

Other:

Required

Fever Check (if over 100.4 they must be sent home) Comprobación de la fiebre (si son más de 100.4 deben ser enviados a casa)

Health Screening completed by: *

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