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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 tested, Cloth Face Coverings.