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COVID-19 Screening Form

Screen patients or visitors for COVID-19 before they arrive — symptoms, exposure and travel captured in seconds.

Description

A COVID-19 screening form lets your practice check patients or visitors for risk before they set foot inside. A few quick questions on symptoms, exposure and travel let you triage who to see in person, who to redirect, and how to protect other patients and staff — captured cleanly rather than asked at the door.

It records the person’s name and date of visit, and asks whether they have key symptoms, have been in contact with a diagnosed case in the last 14 days, or have traveled internationally recently. A question on vaccination status and a signature complete a quick, documented screening record.

Customize the questions to match current guidance, restyle it in your brand colors, and embed it on your site so screening happens before anyone arrives.

Form fields

Everything the COVID-19 Screening Form above collects — 7 fields, so you can see exactly what it captures before you make it your own.

COVID-19 Precautions

  • Name

    Name Icon
    Name

  • Date of Visit

    Date Icon
    Date

  • Do you have a fever, cough, or shortness of breath?

    Yes/No Icon
    Yes/No

  • Have you been in contact with anyone diagnosed with COVID-19 in the last 14 days?

    Yes/No Icon
    Yes/No

  • Have you traveled internationally in the past 14 days?

    Yes/No Icon
    Yes/No

  • Have you been vaccinated for COVID-19?

    Yes/No Icon
    Yes/No

  • Signature

    Short Answer Icon
    Short Answer
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Template FAQs

Common questions about the COVID-19 Screening Form — what it captures, when to use it, and how to make it your own.

What is a COVID-19 screening form?

It’s a form practices use to check patients or visitors for COVID-19 risk before a visit. It asks about symptoms, recent exposure and travel, so you can triage who to see in person and protect other patients and staff, without screening everyone at the door.

What does the form ask?

The person’s name and date of visit, whether they have symptoms like fever, cough or shortness of breath, whether they’ve been in contact with a diagnosed case in the last 14 days, and whether they’ve traveled internationally. It also captures vaccination status and a signature.

When should it be completed?

Before a visit, ideally the same day, so the answers reflect how the person feels right now. Screening ahead of arrival lets you reschedule or redirect anyone at risk before they reach your waiting room, keeping other patients and staff safer.

Who is this form for?

GP practices, clinics, dentists and any provider managing infection risk, and the patients or visitors being screened. It suits any practice that wants a quick, documented screening step in place, adaptable as public health guidance changes over time.

Why ask about recent travel and contact?

Symptoms alone don’t catch everyone — someone exposed or recently traveled may be infectious before they feel unwell. Asking about contact and travel widens the net, helping you spot risk early and take precautions that symptom questions alone would miss.

Is this form free to use?

Yes — it’s free. Create a Fun Forms account, customize the questions to match current guidance, restyle it to your brand, and embed it on your website with no coding. Screening responses then arrive before the visit, ready to review.

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