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This form has been designed to facilitate your daily Health
Self-Assessment. Please review the symptoms below and
indicate with a check box if you have the appropriate
symptoms.
Name: ___________________________ Date: _______
Do you have one or both of these symptoms?
Cough
Shortness of breath or difficulty breathing
Or do you have at least two of the following?
Fever
Repeated shaking with chills
Headache
New loss of taste of smell
Gastrointestinal Problems (nausea, vomitting, or diarrhea)
Chillls
Muscle Pain
Sore Throat
If you experience two or more of the above symptoms, please stay home and contact
your health care provider. Take your temperature every day and keep a record. If
your temperature goes above 100.4 °F (38° C), or for 60 years old and over, 99.6° F
(37.6° C), please stay home. If you do not have access to a thermometer, please
reach out to Madhavi Kadakia , madhavi.kadakia@wright.edu
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Completed 16 December 2020

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