Symptom Screening Form 2026

This eight-question form opens by asking for the respondent's full name and date of birth to tie every response to the correct patient record, then moves to the clinical detail: the primary symptom, when it started, whether a fever is present, and whether breathing difficulties are occurring. The "Have you been in close contact with anyone who has tested positive for an infectious illness or is experiencing similar symptoms?" question gives the medical team an early picture of possible exposure. A final open-ended question lets respondents flag anything not covered before the earlier required fields. After submitting, respondents see a confirmation that their answers have been sent to the medical team for review.