Health screening form template

About this health screening form

A health screening form is a short self-check before someone enters a workplace, joins an event, starts a sport or visits a care home: current symptoms, recent illness or exposure, travel, and a temperature reading if you take one. Anyone answering “yes” is followed up before taking part.

For exercise-specific screening, use the physical activity readiness form, which asks about heart and joint problems.

What’s on the health screening form

The template has 4 sections and 12 questions. Every one can be renamed, moved or deleted.

• Details: Name; Phone; Date; Time; Temperature (if taken)
• Questions: Do you have any of these symptoms today? (tick all that apply: Fever, Cough, Sore throat, Shortness of breath, Loss of taste or smell, Vomiting or diarrhoea, Rash, None); Have you been in close contact with someone with an infectious illness in the last 7 days? (yes or no); Have you travelled outside the area in the last 14 days? (yes or no); Have you been told to isolate by a health professional? (yes or no)
• Declaration: Agreement: “My answers are true. I will tell staff if anything changes.”; Signature with date
• Staff use: Outcome (choose one: Cleared, Not cleared – sent home, Referred)

Tips

• Keep it short so it’s quick at the door.
• Say what happens if someone answers “yes”.
• Don’t keep screening forms longer than you need them.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.