Free Cleaning Services Health Screening Form

Field	Information
Name:
Date of Birth:
Gender:	Male Female Other:

Section	Question	Response
Health History	Do you have any pre-existing medical conditions?	Yes No
If yes, please specify:
Are you currently taking any medication?	Yes No
If yes, please specify:
Symptoms	Do you currently have any COVID-19 symptoms?	Yes No
If yes, please specify:
Exposure Risk	Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?	Yes No
Have you traveled internationally in the past 14 days?	Yes No
Temperature Check	Current Temperature:
Time of Measurement:

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Free Cleaning Services Health Screening Form

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