COVID-19 Wellness Check Assessment Name First Last Date MM slash DD slash YYYY Do you or anyone you are living with currently have or recently had any s/s of a flu-like or respiratory infection such as:Have you experienced any of the following symptoms in the past 48 hours:fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea Yes No Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19? Yes No Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? Yes No Are you currently waiting on the results of a COVID-19 test? Yes No Employee's SignatureDate MM slash DD slash YYYY
