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?
*
Communication / OCC Center
Riverview
Education (9th Floor)
LL2 - Alexandria
LL3 - Willmar
LL4 - Anoka
LL5 - Rice Lake
LL6 - Hibbing
LL7 - Duluth
LL8 - Brainerd
LL9 - Marshfield
LL10 - Rush City
LL11 - Rhinelander
LL12 - Detroit Lakes
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