MTS Seating | Health Screening

Visitor Health Screening

Coronavirus Disease (COVID-19) Visitor Health Screening
Visitor's Name: Visitor's Company: MTS Visitee (who visitor is visiting): Appointment Date: Time In: In the past 24 hours, have you experienced any of the following symptoms? Fever (100.4° or above), Chills, or New Loss of Taste or Smell or Headache or Nausea or Vomiting or Diarrhea? Yes No Atypical Continuous Cough, Sore Throat, or Muscle or body aches? Yes No Atypical Shortness of Breath or Difficulty Breathing or Congestion or Runny Nose? Yes No In the past 14 days, have you had close contact (Someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with an individual diagnosed with COVID-19? Yes No