Health Self-Evaluation Form

Your Information

Name

First

Last

What is your temperature?

Guest 1

Guest Name

Guest First Name

Guest Last Name

What is their temperature?

Guest 2

Guest Name

Guest First Name

Guest Last Name

What is their temperature?

Do you or your guest have any of the following (please check all that apply)

Fever (100.4 or greater) or chills

Cough

Shortness of breath

Difficulty breathing

Body aches

Headache

New loss of taste or smell

Sore throat

None of the above

Have you or your guest been in close contact (within 6’) with someone who has a laboratory confirmed Covid-19 diagnosis within the past 14 days?

- Select -YesNo

If yes, have you been tested?

- Select -YesNo

Date

Result

- Select -PositiveNegative

Submit