Guest screening form - Balmoral Lodge

Date

Name

First Last

Phone

Email

Fever (>38°C) or a history of fever and chills*

Yes
No

Cough (acute onset)*

Yes
No

Sore throat*

Yes
No

Loss of smell and/or loss of taste*

Yes
No

Body aches*

Yes
No

Nausea, vomiting, diarroea*

Yes
No

Fatigue/weakness*

Yes
No

In the last 14 days, in your community,were you in close contact or living with any of the following: a. A person with flu like symptoms or b. A confirmed COVID19 person or a person under investigation for COVID?*

Yes
No

Close contact means were you face-to-face (less than 1 meter) with the person or were you in a closed space (car,taxi or house)with the person for at least 15 minutes

Have you been admitted with severe pneumonia in the last 14 days?*

Yes
No

Guest Covid 19 screening form

Guest Covid 19 screening form