COVID-19Employee Check-in Name * First Name Last Name Date * MM DD YYYY Do you have any of the following symptoms immediately: Trouble breathing? * Yes No Persistent pain or pressure in chest? * Yes No New confusion? * Yes No Bluish lips or face? * Yes No Have you experienced any of the following symptoms in the last 48 hours: Fever? * Yes No Cough? * Yes No Shortness of breath? * Yes No Chills? * Yes No Repeated shakes with chills? * Yes No Muscle pain? * Yes No Headache? * Yes No Sore Throat? * Yes No New loss of taste or smell? * Yes No Gastrointestinal problems? * Yes No Thank you!
