Please submit this checklist BEFORE meeting with an EHS client.

If the answer is YES to a symptom in question #3 OR YES to two or more symptoms in question #4, and/or the client has a temperature of 100.4 or higher, please do not meet with the client. Cancel the meeting and reschedule. Advise the client to self-isolate at home and to contact their primary care physician's office for direction. This survey is to be completed for each home visit and include the names of all that will be participating in the meeting.  EXCEPTION for #6: If answered "yes", you may continue to meet with the client IF they have received the COVID-19 vaccine, and it has been at least 2 weeks since their  final vaccine.  Thank you.

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* 2. What are the clients' names?

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* 3. Ask the client the following questions:
IIn the past 24 hours have you experienced any of the following symptoms not explained by a known medical or physical condition?

  No Yes
Fever
Uncontrolled cough
Shortness of breath

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* 4. In the past 24 hours have you experienced any TWO of the following symptoms not explained by a known medical or physical condition?

  No Yes
Loss of taste of smell
Muscle pain
Sore throat
Severe headache
Diarrhea
Vomiting
Abdominal pain

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* 5. What are the current temperatures of anyone that will be present at the home visit today?  (##.#)

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* 6. Has anyone that will be at the home visit had close contact in the last 14 days with an individual diagnosed with COVID-19? (The CDC defines close contact as being within 6 feet of an infected person for 15 minutes or more.)

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* 7. Have you been directed or told by anyone to self-isolate or self-quarantine?

0 of 7 answered
 

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