Visitor Health Screening Form

Life Link III
Visitor Health Screening Form

This form is to be completed before entering all Life Link III locations.
Name Name * First Last
Phone Phone * - ### - ### ####
Vendor / Employer *
Life Link III location you are entering? *
Date Date * / MM / DD YYYY
Time Time : HH MM
In the past 14 days have you had any of the following?
● Confirmed Positive COVID-19 Test
● Symptomatic for COVID-19 and are awaiting test results
● Been in contact without proper PPE with someone with symptoms who is pending test results or has tested positive within the last 14 days *

In the past 14 days have you had any of the following?
● Confirmed Positive COVID-19 Test
● Symptomatic for COVID-19 and are awaiting test results
● Been in contact without proper PPE with someone with symptoms who is pending test results or has tested positive within the last 14 days No Yes
History Detail:

History Detail: Confirmed Positive COVID-19 Test Tested for COVID-19 and are awaiting test results Been in contact without proper PPE with someone who is pending test results or has tested positive within the last 14 days
Are you currently experiencing any of the following symptoms?

● Fever (feel feverish?)
● Temperature GREATER THAN 100.4°F or 38°C
● Cough
● Shortness of breath / Difficulty breathing
● Sore throat
● Muscle pain
● Loss of taste or smell
● Abdominal Pain or Diarrhea
● Itchy, red eyes
● Nausea / Vomiting
● NEW ONSET Sinus congestion / Runny nose
● Severe headache
● Fatigue
● Chills *

Are you currently experiencing any of the following symptoms?

● Fever (feel feverish?)
● Temperature GREATER THAN 100.4°F or 38°C
● Cough
● Shortness of breath / Difficulty breathing
● Sore throat
● Muscle pain
● Loss of taste or smell
● Abdominal Pain or Diarrhea
● Itchy, red eyes
● Nausea / Vomiting
● NEW ONSET Sinus congestion / Runny nose
● Severe headache
● Fatigue
● Chills No Yes
Symptoms: (select all that apply)

Symptoms: (select all that apply) Fever (feel feverish) Cough Shortness of breath Sore Throat Muscle pain/body aches Loss of taste or smell Abdominal Pain or Diarrhea Itchy, red eyes Temperature GREATER THAN 100.4°F or 38°C Chills Fatigue Severe Headache Nausea / Vomiting

Visitor Health Screening Form

Life Link III Visitor Health Screening Form

This form is to be completed before entering all Life Link III locations.

Life Link III
Visitor Health Screening Form