Health Screening Form-0

Health Screening Form

Your health and safety are our top priority.

Please take a few moments to complete this brief screening form before your visit or start of shift. Your responses help us maintain a safe environment for all patients, employees, and visitors by identifying potential health risks early.

We appreciate your honesty and your commitment to helping us keep our community healthy! 👋

Name
Mobile Phone
Are you currently experiencing any of the following symptoms?
Current body temperature (°C)
Have you traveled outside the local area in the past 14 days?
Have you been in close contact with a confirmed or suspected case of infectious disease in the past 14 days?
I declare that the information provided above is accurate and complete to the best of my knowledge.
Signature
Scan to share