COVID-19 Screening Questionnaire
Guest Full Name
*
First Name
Last Name
Date of Property Visit
*
-
Month
-
Day
Year
Date
Property Address
Are you experiencing any of the following symptoms?
Fever (above 100.4 degrees)
*
Yes
No
Cough or shortness of breath
*
Yes
No
Sore throat
*
Yes
No
Chills
*
Yes
No
Muscle aches or rigors
*
Yes
No
Headache
*
Yes
No
New loss of taste and/or smell
*
Yes
No
Abdominal pain / nausea / vomiting / diarrhea
*
Yes
No
Have you had close contact with someone who is currently sick?
*
Yes
No
Have you been diagnosed with COVID-19 in the past three weeks or have reason to believe you have COVID-19?
*
Yes
No
Have you traveled or had close contact with anyone who has traveled internationally in the last 14 days?
*
Yes
No
If you took your temperature this morning, what was the reading?
degrees
This screening questionnaire must be completed prior to your appointment to view the property, or admission will not be granted.
I certify that the above responses are true and correct at the time of completion, and should any changes be noted between now and the appointment time, I will notify the property management company prior to the appointment.
Signature
*
Submit
Should be Empty: