Please answer these screening questions before your visit.
Healthcare template · 10 fields (10 required) · ~2 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your covid screening form
Please answer these screening questions before your visit.
Update the symptom list to follow current public health guidance and tell people what happens if they answer yes. Keep responses only as long as your policy requires.
The form separates phone number, date of visit, reason for visit, do you currently have any of these symptoms? into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
Update the symptom list to follow current public health guidance and tell people what happens if they answer yes. Keep responses only as long as your policy requires.
Customize the phone number and date of visit questions to match your records and terminology.
Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.
Every field, explained
Your full name (Name, required)
Email address (Email, required)
Phone number (Phone, required) — Used only if we need to reach you about your visit.
Date of visit (Date, required)
Reason for visit (Dropdown, required)
Do you currently have any of these symptoms? (Multiple choice, required) — Choose "None of these" if you feel well.
Have you tested positive for COVID-19 in the last 5 days? (Single choice, required)
Have you been in close contact with someone who tested positive in the last 5 days? (Single choice, required)
Are you waiting on a COVID-19 test result? (Single choice, required)
Confirmation (Multiple choice, required)
Frequently asked questions
What does this covid screening form template collect?
Alongside contact details, it asks for phone number, date of visit, reason for visit, do you currently have any of these symptoms?, have you tested positive for covid-19 in the last 5 days?, have you been in close contact with someone who tested positive in the last 5 days?, are you waiting on a covid-19 test result?, confirmation. You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this covid screening form form?
Update the symptom list to follow current public health guidance and tell people what happens if they answer yes. Keep responses only as long as your policy requires.
Can I edit this form and print a copy?
Yes. Open an editable draft, adjust the questions, and review the preview before publishing. You can also use the template page’s print option. Publishing requires an account; the draft can be tried first.