Wellness Screen Sample | Health Assessment

Please fill the form below and complete the Wellness Assessment Screen

June 2, 2020

Name & Surname

ID Number

Cell Number

Email Address

Residential Address

Area Ward

1. Do you have a cough?

Yes

No

2.

Do you have a cold?

Yes

No

3.

Are you having Diarrhea?

Yes

No

4.

Do you have a sore throat?

Yes

No

5.

Are you experiencing MYALGIA or body aches?

Yes

No

6.

Do you have a headache?

Yes

No

7. Do you have fever (Temperature 37.8C and above)

Yes

No

8.

Are you having difficulty breathing?

Yes

No

9.

Are you experiencing fatigue?

Yes

No

10.

Have you travelled recently within the past 14 days?

Yes

No

11.

Do you have a travel history to a COVID-19 infected area?

Yes

No

12.

Do you have direct contact or taking care of a COVID-19 positive patient?

Yes

No

We Care About Your Health