Nursing Home Visitor Health Screening Checklist
Before entering the premises, please complete the following checklist to streamline the health screening process. Answer each question honestly and check the box that corresponds to your response.
Visitor Information
Field | Information |
|---|
Name: | |
Email Address: | |
Phone Number: | |
Resident: | |
Relationship to Resident: | |
Date: | |
Health Screening
Question | Yes | No |
|---|
Have you experienced any COVID-19 symptoms such as fever, cough, shortness of breath, or fatigue? | | |
Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days? | | |
Have you traveled internationally in the past 14 days? | | |
Do you have a fever of 100.4°F (38°C) or higher? | | |
Have you been advised by a healthcare professional to self-quarantine? | | |
Have you tested positive for COVID-19 in the past 14 days? | | |
Have you experienced any symptoms of respiratory infection in the past 72 hours? | | |
Have you recently lost your sense of taste or smell? | | |
Have you visited any crowded or high-risk areas in the past week? | | |
Are you currently under quarantine orders mandated by local health authorities? | | |
Travel History
Date of Travel | Destination | Purpose of Travel | Duration of Stay |
|---|
| | | |
| | | |
| | | |
| | | |
| | | |
Health Declaration
I declare that the information provided above is true and accurate to the best of my knowledge. I understand the importance of maintaining a safe environment within the nursing home premises and agree to abide by all safety protocols and guidelines.
Date: [Month Day, Year]
Thank you for completing the health screening checklist. Your commitment to ensuring the safety and well-being of our residents and staff members is deeply appreciated.
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