Platinum Senior Care Stay Well
COVID-19 Start-of-Shift Screening Form
Date
*
-
Month
-
Day
Year
Date
CarePro Name
*
First Name
Last Name
What is your temperature?
*
NORMAL
100+
Unknown
Do you have any of the following symptoms?
*
New and persistent cough
Shortness of breath or any difficulty breathing
Sore throat
Chills
Cough
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea
NO SYMPTOMS
To your knowledge, have you been in contact with anyone in the last 14 days who is experiencing any of these symptoms?
*
YES
NO
To your knowledge, have you been in contact with anyone who has tested positive for COVID-19 or is under investigation for COVID-19 in the last 14 days?
*
NO
To your knowledge, have you or anyone you've had contact with, traveled to any country with COVID-19 travel advisories or restrictions in the last 14 days?
*
YES
NO
THE SECTION BELOW IS FOR YOU TO ASK THE CLIENT AND ANYONE LIVING/STAYING IN THE HOME
Client Name
*
First Name
Last Name
What is the Client's temperature?
*
NORMAL
100+
Unknown
Does the Client OR Anyone living/staying in the home have any of the following symptoms?
*
New and persistent cough
Shortness of breath or any difficulty breathing
Fever
Sore Throat
NO SYMPTOMS
Does the Client OR Anyone living/staying in the home have any of the following symptoms?
*
New and persistent cough
Shortness of breath or any difficulty breathing
Sore throat
Chills
Cough
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea
NO SYMPTOMS
To their knowledge, has the Client OR Anyone living/staying in the home been in contact with anyone in the last 14 days who is experiencing any of these symptoms?
*
YES
NO
To their knowledge, has the Client OR Anyone living/staying in the home been in contact with anyone who has tested positive for COVID-19 or is under investigation for COVID-19 in the last 14 days?
*
YES
NO
To their knowledge, has the Client OR Anyone living/staying in the home or anyone they've had contact with, traveled to any country with COVID-19 travel advisories or restrictions in the last 14 days?
*
YES
NO
SUBMIT
Should be Empty: