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Coronavirus-19 Health Declaration Form Template

Streamlined Health Declaration for COVID-19 Compliance

Navigating health concerns during the pandemic can be overwhelming. This Coronavirus-19 Health Declaration Form template is designed for healthcare providers and organizations to efficiently gather crucial information from individuals who may have been exposed to the virus. With customizable questions, you can ensure accurate data collection, maintain compliance with health regulations, and enhance patient safety, all while creating a user-friendly experience. Plus, the form is equipped with WCAG-aligned labels for enhanced accessibility. Explore how this practical tool can support your efforts today.

Use this Template (FREE) Live Preview
Full name
Email address
Mobile phone number
Intended date of visit or activity
In the past 10 days, have you had any of the following symptoms?
In the past 10 days, have you tested positive for COVID-19?
Yes
No
Test date for your most recent positive COVID-19 result (if applicable)
In the past 10 days, have you been identified as a close contact of someone with COVID-19?
Yes
No
In the past 10 days, have you been advised to isolate or quarantine by a public health authority?
Yes
No
In the past 10 days, have you traveled internationally and stayed overnight?
Yes
No
Countries or territories visited and dates (if applicable)
In the past 10 days, have you worked or stayed in high-risk settings such as healthcare, long-term care, or correctional facilities?
Yes
No
Date of your most recent COVID-19 vaccine dose
What is your COVID-19 vaccination status?
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
I attest that the information provided is true and accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Type your full legal name as your signature
Signature date
I acknowledge that this declaration is not a diagnosis or medical advice and that entry decisions may be based on local guidelines.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration related to Coronavirus-19 health declaration form template and FormCreatorAI.

When to use this form

Use this form before in-person work, classes, events, or clinic visits to screen for COVID-19 risk. It helps employers, schools, and healthcare teams decide who can enter, who needs masking or testing, and who should reschedule or use telehealth. For patients heading to care, pair the screening with a Hospital admission form to streamline check-in. After a visit, you can align follow-up steps with a Discharge instructions form. Typical scenarios: employees clocking in for shifts, visitors arriving at a ward, or students returning from travel. The outcome is faster triage, safer spaces, and clear next steps.

Must Ask Coronavirus-19 Health Declaration Questions

  1. Do you currently have any of these symptoms (fever, cough, shortness of breath, loss of taste or smell)?

    Symptoms suggest active infection and higher transmission risk. Clear symptom data helps you decide on entry, PPE, testing, or remote options.

  2. Have you tested positive for COVID-19 in the past 10 days, or are you awaiting results?

    Recent positives or pending tests indicate you should delay entry and follow isolation guidance. This reduces exposure for staff and visitors.

  3. In the last 14 days, have you had close contact with someone who tested positive?

    Exposure timing helps you apply quarantine or testing rules. It also supports contact tracing if an outbreak occurs.

  4. What is your COVID-19 vaccination and booster status?

    Vaccination status can inform symptom thresholds, masking, and testing cadence. Collecting it upfront prevents back-and-forth and speeds screening.

  5. Do you consent to share your responses with your care team if follow-up is needed?

    Documented consent ensures you can coordinate care or referrals legally and quickly. If sharing records is required, include a Medical record release form.

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