Platinum Senior Care Stay Well
COVID-19 Visitor Screening Form
COVID-19 QUESTIONS TO ASK EACH Guest/Family Member/Spouse
Date
*
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Guest/Family Member/Spouse Name
*
First Name
Last Name
Are they running a fever?
*
Yes
No
Unknown
Do they 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 Guest/Family Member/Spouse been in contact with anyone in the last 14 days who is experiencing any of these symptoms?
*
YES
NO
To their knowledge, has the Guest/Family Member/Spouse 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 Guest/Family Member/Spouse 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: