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Health Declaration Form Template

Ensure Safety with a Custom Health Declaration Form

Managing health information can be challenging, especially when it comes to ensuring safety at events or workplaces. This Health Declaration Form Template helps you gather crucial health details from travelers, employees, students, and visitors, ensuring compliance and safety. You can easily collect data on symptoms, vaccination status, and travel history, promote a safer environment, streamline the onboarding process, or enhance public health efforts-all with a simple and user-friendly form. Dive into the live template to see how it works for you.

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Full name
Date of birth
Email address
Mobile phone number
Gender self-description (if applicable)
Home address or city (optional)
Date of declaration
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Do you feel unwell today?
Yes
No
Not sure
In the past 24 hours, have you had a fever (over 100.4 F / 38 C) without using fever-reducing medication?
Yes
No
Not sure
In the past 14 days, have you experienced any of the following symptoms?
Do you have any ongoing health conditions relevant to this visit?
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Are you taking any medications that suppress your immune system (e.g., steroids, chemotherapy)?
Yes
No
Not sure
Prefer not to say
In the past 14 days, have you had close contact with anyone who was ill with a contagious condition?
Yes
No
Not sure
Prefer not to say
In the past 14 days, has anyone in your household had new infectious symptoms (e.g., fever, cough, vomiting, diarrhea)?
Yes
No
Not sure
Prefer not to say
If you traveled, list locations and dates (optional)
In the past 14 days, have you traveled outside your state or country?
Yes
No
Prefer not to say
In the past 14 days, have you been tested for an infectious illness?
Yes
No
Prefer not to say
If tested, what was your most recent result?
Positive
Negative
Inconclusive
Awaiting results
Not applicable
Prefer not to say
Date of most recent vaccination (optional)
Are your vaccinations up to date for your age or this visit?
Yes
No
Not sure
Prefer not to say
May we contact you if follow-up is needed regarding this declaration?
Yes
No
Signature (type your full name)
Signature date
I certify that the information provided is accurate and complete to the best of my knowledge.
Yes
No
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Colorful paper art illustration representing a health declaration form template and its usage in FormCreatorAI

When to use this form

This form helps you screen health risks before work, events, appointments, or facility entry. Use it for employees returning to the office, patients checking in, visitors to clinics, or participants in classes and camps. It captures symptoms, recent exposure, and key medical details so you can decide on entry, extra precautions, or follow-up care. If you collect lab evidence, you can route results with the COVID-19 Test result reporting form. When exposure needs tracking, pair responses with the Contact tracing form to notify close contacts faster. The result is a clear record that supports safety decisions, protects staff and guests, and keeps your policy consistent.

Must Ask Health Declaration Questions

  1. Do you currently have any symptoms such as fever, cough, shortness of breath, or loss of taste or smell?

    This identifies immediate risk and helps you decide on on-site care, masking, or deferral. Clear symptom lists reduce guesswork, so respondents give consistent, comparable answers.

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

    This determines whether isolation or remote service is required. If positive results must be documented, pair with the COVID 19 positive diagnosis form.

  3. Have you had close contact with a confirmed infectious case in the past 14 days?

    This assesses exposure risk even without symptoms. It supports follow-up monitoring and protects others who share the space.

  4. Do you have any chronic conditions, allergies, or medications we should consider today?

    These details guide safe accommodations, dosing, and activity limits. They also prevent contraindications, such as offering alternatives if someone has a severe allergy.

  5. Do you consent to share this information with your designated provider or employer if needed?

    Consent lets you share only what is necessary to coordinate care or workplace safety. For verified record movement, use the Transfer of medical records form.

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