Wellness Screening Checklist
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Appointment Date *
MM
/
DD
/
YYYY
Client Name *
Email address *
Phone Number *
Appointment with: *
Symptom Wellness Check:
Have you experienced any of the following symptoms within the last 14 days? *
No
Yes
Fever or feeling feverish?
New Cough?
Shortness of Breath
Flu-like symptoms such as fatigue, nausea, diarrhea? Chills? Repeated shaking with chills? Muscle pain? Headache? Sore throat?
Have you been diagnosed or suspected of having Coronavirus or COVID-19? *
If so, when?
Have you been tested for Coronavirus or COVID-19? *
If tested, was testing performed by nasal swab or blood test?
Clear selection
If tested, did you test Positive or Negative?
Clear selection
Have you had an antibody test for Coronavirus? *
If tested, did you test Positive or Negative?
Clear selection
If known, was the test for IgM or IgG antibodies?
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Family and Close Contacts:
Are any of your family members or immediate/close contacts currently sick or experiencing fever, cough, shortness of breath, or flu-like symptoms (sore throat, muscle aches, fatigue, nausea and diarrhea)? *
Have any of your family members or immediate/close contacts been diagnosed with Coronavirus or COVID-19? *
If yes, when?
Recent Travel:
Have you recently travelled in the U.S. or Internationally? *
If yes, when?
Have any of your family members recently travelled in the U.S. or Internationally? *
If yes, when?
Notes:
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