Covid-19 Screening Tool

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Colorado State Emergency Operations Center (SEOC) Wellness Screening 

& 

Joan DePuy

DATE: ___________________

Name: ________________________________ 

Do you have a fever? Yes: _________ No: _________

Temperature Reading: ______________________

Within the last 14 days have you experienced or do you now have any of the following symptoms?

Dry Cough: ________

Shortness of Breath: _________

Sore Throat: _______________

Loss of taste or smell: ____________

Nasal Congestion: ______________

New Onset/Unexplained Muscle Aches: ________________

None: ____________

Within the last 14 days, have you had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?* (Note: Close contact is defined as within 6 feet for more than 10 consecutive minutes)? ____________________

Within the last month have you traveled outside of our state: ___________________?

If Yes, where? _________________________________________________

By signing this form I am affirming that the above is true. In addition, I will not hold Joan DePuy, liable should I become Covid-19 positive. However, in the event of a positive Covid-19 diagnosis, I will make Joan DePuy aware with dates and symptoms.  

Client Signature:_____________________________________Date:_______________________

Practitioner Signature: ________________________________Date:_______________________ 

 Created: 6-20-20; Revised 11-24-2022