Daily Resident / Visitor Health Screen Question Title * 1. Date Date / Time Date Time AM/PM - AM PM Question Title * 2. Resident or Visitor's Name Question Title * 3. Current Temperature Question Title * 4. Is the temperature greater than 99.9F Yes No Question Title * 5. Does resident/visitor have a cough that is new or an existing cough that is worsening? Yes No Question Title * 6. Does resident/visitor have shortness of breath that is new? Yes No Question Title * 7. Does resident/visitor have any additional concerning symptoms such as sore throat, frequent sneezing, runny nose, unusual body aches, or chills? No - nothing new Yes - sneezing / runny nose Yes - sore throat Yes - unusual body aches / chills Question Title * 8. If you answered yes to any of the above yes/no questions do not allow the visitor to enter the home until you speak with a nursing supervisor for PDHH. If you answered yes to any of the above yes/no questions for a resident, please take them to their room and notify the nurse supervisor for further instructions. Resident / Visitor Passed Health Screen I called the nursing supervisor - visitor denied entry I called the nursing supervisor - resident taken to room Question Title * 9. Staff name who completed the survey Submit