Health Screening Form

Cough (new onset or worsening) *
YesNo

Shortness of breath / difficulty breathing *
YesNo

Sore throat *
YesNo

Difficulty swallowing *
YesNo

Lost sense of taste or smell *
YesNo

Chills *
YesNo

Headaches *
YesNo

Unexplained fatigue / malaise / muscle pains *
YesNo

Pink Eye *
YesNo

Nausea / Vomiting, Diarrhea, Abdominal Pain *
YesNo

Delirium (70 yrs or older) *
YesNoN/A

Increased or unexplained falls (70 yrs or older) *
YesNoN/A